Medical Electronic Document Imaging and Records Retention



More and more hospitals and physicians are choosing to move away from paper medical filing systems and gain the benefits of electronic medical records imaging systems, which offers quick and easy as well as multiple, simultaneous access to patient medical records, charts and medical histories of patients to all medical care providers, without having to search files or wait for clerks to get the information.

Replacement of paper based medical filing systems with document management system, including clinical, administrative and financial information, with electronic retention and disposal medical records systems provide a consolidated workflow and efficiency system. Better document organization and faster retrieval and re-filing medical records are also benefits of electronic medical records systems. Reduction of paper to be stored is also significant, as well as freeing of office space for uses other than medical record storage systems, are also important benefits of electronic medical records management, as medical records stored in digital format take up little room.

In addition to the above improvements, there is also improvement in confidentiality, as medical records are protected based on hospital-defined rules and user profiles, and all the files can be secured at document level with password security when medical electronic document imaging and management is used. This security helps keep a practice in compliance with the Gramm-Leach-Bliley Act, which addresses "patient privacy issues", and the Health Insurance Portability and Accountability Act (HIPAA), which addresses sharing electronic information.

Medical electronic document imaging and management reduces waiting time, and provides the consequent improvement in service quality. When patients call the office with some questions, the file can be immediately accessed, thus providing the patient with the information he or she needs swiftly. Medical electronic document imaging and management eliminates the need for call-backs, messages and answering machines, thus making the patients feel that they are receiving more personalized care, which is among most important benefits of electronic medical records management.

Retention, Storage and Disposal Medical Records Policy

Medical records are kept for a variety of reasons, from the requirement to document patient care to assist in a case of a claim regarding care and treatment. In a medical malpractice case, the original medical records are the best evidence. Re-created or photocopied records are not admissible except under the most extraordinary circumstances. Document management system there is also the possibility of additional claims if medical records are lost or destroyed due to intentional acts or negligence. And different states have varying lengths of time for bringing a lawsuit for professional negligence.

In states where there are no specific regulations or federal record retention guidelines on medical record retention schedule, American Healthcare Indemnity (AHI) recommends that records be retained indefinitely, or if that’s not possible, for a minimum of 10 years after the last contact, but preferably 25 years.

The best source for this thematic might be HIPPA Advisory on medical records retention schedule, based on the new HIPAA regulations. 

"According to the proposed privacy regulation, documents relating to uses and disclosures, authorization forms, business partner contracts, notices of your information practice, responses to a patient who wants to amend or correct their information, the patient's statement of disagreement, and a complaint record must be maintained for 6 years. (See 64 Fed. Reg. 59994). This is the federal statute of limitation for civil penalties. (42 CFR Part 1003). It is the amendment why hospitals and other health care providers maintain medical records as well as billing records on Medicare (Title XVIII), Medicaid (Title XIX), and Maternal and Child Health (Title V) for at least 6 years. Records must also be retained for two years after a patient's death under HIPAA. The Medicare Conditions of Participation, section 42 CFR 482.24 (b), states that all hospitals must retain medical records in their original or legally produced form for a period of 5 years.

Facilities should also give consideration to the statute of limitation, or time period for suing, in determining their retention and disposal medical records policy. Many facilities will retain the medical records of minors for longer periods of time, sometimes until they are at least 21 years of age. The medical records should be retained for a patient who institutes a malpractice or wrongful suit against a facility. Generally, facilities select longer retention periods because of the concern of having the medical records available for defense purposes for litigation."

Information on a number of other keeping and disposal medical records laws required by the federal record retention guidelines schedule and laws that have specific record-keeping requirements could also be found on HIPPA Advisory Home Site, and especially on HIPPA Advisory on Record Retention Periods page.

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