Record Keeping: Taming the Paper Blob

If the desk drawers, file cabinets, closets, cabinets, and shelves in your office are threatening to burst, it is time to purge, save, or store. Unfortunately, the healthcare field often handles every piece of paper as if it were a medical record, keeping it indefinitely. When in doubt as to the future usefulness of a piece of written information, we often create a tidy filing place, only to discover months if not years later, that it has been in obscurity for so long that we forgot why we originally saved it.

If your office is typical, there is a severe lack of storage space. Compounding this dilemma is a lack of time to do anything about it. With a little planning, your office can overcome the paper problem.

What To Save

To begin your planning, you will need to establish goals and objectives. The goal is to clean out the excess, while saving and storing the necessary. The objectives are multiple: to accomplish your goal with little disruption to the office; in as little time as possible; and to establish criteria for the retention of written information, which will help to minimize future storage problems.

Identifying the information that must be retained for current access is an easy place to begin the task. Even so, establishing and following guidelines will be useful to determine exactly how the information should be retained or stored.

. Is the information only for one person's use or will others need it as well? If the purpose of the document was to inform one person, and that person is now informed, is it still needed?

. Will you or others need the information again? If there is no legal reason to keep it, or you can't answer affirmatively, it could probably be discarded.

. Are there other formats that could store this information (i.e., electronically)? Storing settled insurance claims on computer media can eliminate the need to store paper copies.

. Is the information outdated? Once office or personnel policies, equipment or property leases, contracts or other such documents have been superseded with updated copies, discard the old ones.

Definitions

The following definitions will help you to determine which records or papers to keep, why to keep them and the period of time for which they must be kept. You can then determine from the table that follows the type of storage that will provide access to records that might be required in the future.

(1) Medical records should include all patient interactions, history/physicals, treatments, procedures etc., along with any evidence of patient non-compliance.

Inactive medical records should be removed from active files once or twice per year to make room for new patient records. The criteria used to determine inactive records will vary by specialty. A recommendation is to store inactive patient records in their paper form, in storage file boxes either on-site or off for two years where they will be easy to retrieve should a patient return to the practice. If, after a two-year period, the patient has not returned, transfer the record to microfiche or other electronic storage media. If your patient records are currently maintained on computer media, make sure there are permanent backup copies as well. As long as the computer media is maintained to ensure future readability, there is no need to retain paper copies. However, your computer records must also indicate the doctor's initials or signature for all entries. Also, if you cannot guarantee that the integrity of the software program will be maintained in your office to run the media in the future (switching or upgrading programs), we recommend maintaining the original paper copies and transferring to microfiche.

(2) Accounting records include canceled checks, bank statements, paid invoices, insurance claims (Medicare and Medicaid) and patient transaction records, records of all depreciable or amortizable assets, payroll tax reports and employee earning records, investment and retirement plan records, and all accounting statements.

(3) Personnel records include job applications, wage and performance reviews, employee medical records (HBV vaccination and exposure incidents).

(4) Regulatory records include training records, employee illness and injury records, patient test requisitions, and particularly material safety data sheets. MSDSs of products no longer used by your practice, but which employees used and were exposed to at one time, must be retained for 30 years from the date of discontinuance, unless you maintain, within your chemical inventory, the names, dates and locations of product use, in which case you can discard the original MSDSs.

How to Retain

Type of Record	Length of Retention	Reason for Retention	Recommended Storage
Medical Records (1) (Not including insurance or billing information; see Accounting Records.)	Indefinitely	Litigation	Microfiche/Computer Off Site
Accounting Records(2)	3 to 7 years (Check with your accountant to determine the length of retention for various records)	IRS audits Medicare/Medicaid audits Patient/Employee Litigation	Paper or Computer Format/Off Site
Personnel(3)	30 years	Dept. HHS	Paper or Computer/Off-site
Regulatory Records(4)	2 to 30 years	OSHA/CLIA/HIPAA	Paper or Computer/Off-site

Other business records such as corporation by-laws, general ledgers, partnership agreements, and income tax returns should be saved permanently. They can be stored off-site, but should be identified in such a way as to prevent their inadvertent disposal.

When in doubt about a specific document, avoid the temptation to just hang on to it. Instead, contact a legal professional, your state medical society, or federal government office for instruction. You may find that you are able to dispose of the document sooner than you think.

When discarding paper, be sure you are not violating any confidentiality laws and ensure that the information won't fall into the hands of criminals. Professional thieves look for bank account and charge card numbers in waste bins. For security purposes, consider recycling facilities and/or paper shredding.

Off-Site Storage

Off-site storage must be as secure as possible to ensure the safekeeping and confidentiality of records, and yet allow access at any time.

Before any records are moved to off-site storage, make sure that the year of the record is easily identified on the outside of the storage box or file used. Make a note in your calendar each year to then discard or transfer to microfiche records that have passed their archival period. This is as important a step as purging the active patient files. Without this step, your off-site storage will require nothing short of warehouse capacity.

AUTHORS NOTES

Healthcare professionals often handle every piece of paper as if it were a medical record, hanging on to it indefinitely.

Is the information in question for one person's use only, or will others need it as well? Will you or others need the information in the future? Are there other formats that could store the information (i.e., electronically)? Is the information outdated?

The definitions provided within this article will help you to determine which records or papers to retain, why they must be kept, and the length of time to keep them.

Off-site storage must be as secure as possible to ensure the safekeeping and confidentiality of records and yet allow your access at any time.

Before any records are moved to off-site storage, make sure that the year of the record is easily identified on the outside of the storage box or file used.

Used with permission from American Practice Advisor www.eagleassociates.net