By Tammie Smeltz
While many healthcare providers have already completely embraced the electronic health record, some practices still find the need to dispose of paper records and imaging. The following is some general information to consider when destroying paper medical records and imaging.
Regulatory Requirements for Retaining Medical Records
The New York State Department of Health requires medical professionals to retain medical records and imaging (“records”) from adult patients for six years. Records for minor patients should be kept for six years and until one year after the minor reaches the age of 21 (whichever is longer). Hospitals are required to keep records from adult patients for six years after the date of discharge. Regarding minors, a hospital is required to keep records for six years after the date of discharge or three years after the patient reaches 21 (whichever is longer). However, MLMIC recommends hospital records be maintained for the same time periods as physician office records. For deceased patients, records should be kept for six years after death.
Keep in mind that failure to retain original medical records for the above time periods is considered professional misconduct and can result in fines, monetary penalties and licensure actions for violations.
HIPAA Requirements for Shredding Medical Records
There are many things to consider when moving medical records out of storage for destruction. Initially, any medical records that are moved out of storage must be documented on a log. HIPAA requires healthcare providers to shred all documents that contain social security numbers, names and addresses, birthdates, medical histories, prescriptions, test results and vaccination records. As a provider, you must always remain mindful of patients’ protected health information.
Options for Destroying Medical Records
There are several ways to dispose of medical records once you identify which records can be destroyed. Here are a few suggestions:
In-House Shredding: If you decide to destroy medical records in-house, a HIPAA-compliant cross-cut shredder is recommended. It is imperative that the shredder you purchase meets the standards set forth in the HIPAA regulations. HIPAA requires documents to be shredded so they are not only unreadable but also cannot be recreated. This option can become expensive due to the purchase of the shredder, as well as the labor costs of manually shredding medical records.
Burning: While burning guarantees the complete destruction of paper records, it is not an eco-friendly option.
Off-site Shredding: When utilizing a professional shredding service, you will need to execute a Business Associates Agreement. Typically, medical records would be placed in a locked bin and retrieved by a representative of the shredding service. The bin is transported to a facility for processing. The company should provide you with a Certificate of Destruction after each shredding service.
Mobile Document Shredding Service: With this option, you will also need a Business Associates Agreement. A mobile service will come to your office at which time both a representative of your practice, as well as the service, will oversee the process. Once the shredding is complete, a Certification of Destruction should be provided. This appears to be the most common and cost-effective way to appropriately destroy medical records.
All the same HIPAA rules and regulations apply to the disposal of imaging. Imaging can be destroyed by shredding, burning or pulverizing the films so they are unreadable. The most secure way to destroy imaging is to hire a professional service. As with paper records, you will need a HIPAA Business Associate Agreement and a Certificate of Destruction.
If you are scanning original paper records into an EMR system, MLMIC recommends retaining the paper records for at least 90 days. We recommend thoroughly examining all records before scanning to determine if any of the records are double-sided. If a patient has had an untoward outcome or a request for records has been received from an attorney or government agency that signals a potential claim, lawsuit or government investigation, the original paper records must not be destroyed and should be locked up and retained until the claim lawsuit or investigation is closed.
For specific questions about shredding paper records or destroying images, please contact the MLMIC Legal Department at (844) 667-5291.
Photo by Christa Dodoo on Unsplash
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