Maintaining up-to-date patient records is essential. Patient records help you monitor changes in your patients’ health and keep track of crucial information that allows you to provide the best possible practice. Also, as physicians, we’re bound by law to make those records available upon request. Over the years, the regulations have evolved and become more cumbersome.
Let’s review some of the common questions about patient records and ways to streamline your practice.
How long do I need to store medical records?
States have different guidelines and laws on how long you should store patient records. For example, while the state of California has no statutory requirements, the California Medical Association recommends that practices retain records for at least 25 years or preferably indefinitely.
Check on what your state requires, but in general, we recommend that you hold on to adult records for 10 years after the last date the patient was seen. For minors, store the files for 28 years from the patient’s date of birth. If you have a patient that passes away, keep their medical records for 5 years after their date of death.
Do I need to keep copies of X-rays?
Yes, you need to keep videos, x-ray films, EKGs, fetal monitor strips, and photos. Any diagnostic, clinical, or demographic data collected during an appointment is part of the medical/legal document.
If a patient brings his or her past medical records to my office, am I required to maintain all of the copies?
You don’t need to keep copies of everything, but you should review the records and extract and copy any information that you might need before returning the documents to the patient. Then you can incorporate any copied data into the patient’s permanent office record. The reason that you don’t keep all of the patient’s records is that you may be held liable for information related to other specialties.
Who is allowed to request patient records?
HIPAA gives patients the right to request copies of their medical records. However, HIPPA also includes strict privacy guidelines about who can receive a copy of an individual’s medical records. In almost all cases, only the patient or their designated representative may request a copy of the patient’s medical records. The patient needs to have completed a release of information to identify a specific person as a representative. In some states, a person with health care power of attorney can request records as a representative.
Even if a patient has passed away, first you need to confirm that the patient is deceased and the requestor must provide an official document from the state showing that they are the patient’s executor or another qualified representative.
How much time is my staff going to spend on patient record requests?
The short answer? Too much. Even if you have a staff member who can manually complete responses to four patient records requests in an hour, that’s still taking their time away from patient care and other more profitable administrative tasks.
That’s why we developed e-Paper Road. This innovative software takes the work out of responding to patient requests. When someone makes a request, your office staff simply directs them to a website, where they log on and provide proof of identification. Our software accesses your EHR system via a secure, encrypted connection to pull the appropriate records and deliver them to the requestor. Your team can then spend their time on more important and valuable tasks.