Medical Records Retention Guide (Updated for 2024)

HIPAA Compliance and Effective Healthcare Management

Medical Records Retention Guide

Effective medical records retention is a crucial component of providing quality care to your patients.

Not only does a proper retention schedule help protect patient privacy and enhance data security, but it also plays a pivotal role in healthcare management.

In our guide, we will explore medical records retention requirements, the role of the Health Insurance Portability and Accountability Act (HIPAA) in record retention, and industry best practices for managing medical records efficiently and securely.

Implementing these strategies can help ensure compliance with relevant laws, safeguard sensitive patient information, and promote efficiency in the handling of health records.

Quick Links:

  1. What is Medical Records Retention?
  2. Why is It Important?
  3. HIPAA and Medical Records Retention
  4. State Specific Medical Retention Laws
  5. Best Practices
  6. Key Components of an Effective Medical Retention Policy
  7. How To Create and Implement a Medical Record Retention Schedule
  8. Secure and Compliant Record Destruction
  9. The Role of Electronic Health Records (EHR) in Medical Records Retention

What is Medical Records Retention?

Medical records retention is the process of maintaining and storing patient health information (PHI) for a specific period of time as required by law. This includes electronic and paper-based records that contain private medical information, including diagnoses, treatments, clinical notes, lab results, and medical history.

Proper medical records retention is an important aspect of patient care that contributes to the overall effectiveness of the healthcare system.

It is recommended that healthcare organizations properly maintain their records to ensure successful long-term patient treatment, as well as to address any potential medical malpractice suits, licensing board complaints, and medical billing audits.

Why is Medical Record Retention Important?

Medical record retention and proper destruction are essential for healthcare organizations for several reasons:

  • Legal Compliance: Healthcare organizations must adhere to federal and state regulations governing the storage and disposal of PII and PHI. Non-compliance can result in penalties, fines, and legal issues.
  • Continuity of Care: Retaining accurate and up-to-date medical records helps ensure seamless care and communication between healthcare providers.
  • Operational Efficiency: Properly organizing and storing records promotes better resource management and streamlines medical record retrieval processes.
  • Risk Management: Implementing a comprehensive retention and destruction policy reduces the likelihood of breaches and legal disputes arising from improper handling of medical records.
  • HIPAA Compliance: Ensuring patient privacy and data security is a top priority for healthcare organizations, and adhering to the Health Insurance Portability and Accountability Act (HIPAA) is essential.
  • Cost Savings: By securely destroying outdated or unnecessary medical records, healthcare organizations can reduce their storage costs and minimize the risk of data breaches.
  • Improved Quality of Care: Properly maintained records establish a documented history of the treatment and care provided to each patient.

HIPAA’s and Role In Records Retention

Does HIPAA Have Retention Requirements?

HIPAA does not specify a particular time frame for medical record retention, primarily because such retention periods can vary significantly from state to state, the type of healthcare provider, and the kind of records in question.

Instead, HIPAA defers to state medical records retention laws regarding the length of time medical records should be retained.

Why Doesn’t HIPAA Retention Requirements?

  1. HIPAA Focus: HIPAA primarily focuses on how protected health information (PHI) should be handled, used, and disclosed, rather than how long such information should be retained. The emphasis is on maintaining the privacy and security of patient information.
  2. State Regulations: Each state in the U.S. already has its own laws governing medical record retention. These laws specify the minimum time that medical records should be kept, and these periods can vary widely from state to state.
  3. Type of Records and Entities: The retention period can also depend on the type of medical record and the nature of the healthcare entity. For example, records for adult patients, minors, psychiatric patients, and other special categories might have different retention requirements.
  4. HIPAA’s Six-Year Requirement: While HIPAA itself does not mandate a specific retention period for medical records, it does require certain documentation (such as policies, procedures, and various records related to its Privacy and Security Rules) to be retained for a minimum of six years from the date of its creation or the date it was last in effect, whichever is later.
  5. Best Practices: Given the lack of specific HIPAA guidance on medical record retention and the variation in state laws, healthcare providers are advised to establish their own record retention policies. These policies should comply with the longest applicable retention period mandated by state law, accreditation requirements, or any other relevant regulations.
  6. Purpose of Retention: The retention of medical records serves multiple purposes, including ongoing patient care, legal protection, and compliance with other regulatory requirements.

State-Specific Medical Records Retention Laws

In addition to HIPAA, healthcare organizations must comply with state-specific medical records retention laws. These laws may vary in terms of retention periods and requirements, so it is crucial to understand the regulations in your jurisdiction. For instance, some states mandate a longer retention period for specific types of records, such as those involving minors or substance abuse treatment.

State Law, Code, Or Regulation Medical Doctors Hospitals
Alabama ALA. ADMIN. CODE r. 420-5-7-.13 As long as may be necessary to treat the patient and for medical legal purposes. 5 years
Alaska ALASKA STAT. § 18.20.085 6 years as stipulated by HIPAA Adult patients: : 7 Years after patient discharge Minor patients: (Under 19): 7 Years after discharge or when the patient reaches the age of 21, whichever is longer.
Arizona ARIZ. REV. STAT. ANN. § 12-2297 Adult patients: 6 years after the last date of services. Minor patients: 6 years after the last date of services, or until patient reaches the age of 21. Adult patients: 6 years after the last date of services. Minor patients: 6 years after the last date of services, or until patient reaches the age of 21 whichever is longer.
Arkansas ARK. CODE R. § 007.05.17 6 years as stipulated by HIPAA. Adult patients: 10 years after the last discharge, but master patient index data must be kept permanently. Minor patients: Complete medical records must be retained 2 years after the age of majority (i.e., until patient turns 20).
California 22 CA ADC §70751 6 years as stipulated by HIPAA. Adult patients: 7 years after discharge. Minor patients: 7 years after discharge or 1 year after the patient reaches the age of 18
Colorado 6 COLO. CODE REGS. § 1011-1: IV-8.102 6 years as stipulated by HIPAA. Adult patients: 10 years after the most recent patient care usage. Minor patients: 10 years after the patient reaches the age of majority (i.e., until patient turns 28).
Connecticut CONN. AGENCIES REGS § 19-13-D3 7 years from the last date of treatment, or, upon the death of the patient, for 3 years. 10 years after the patient has been discharged.
Delaware DEL. CODE ANN. tit. 24 § 1761 7 years from the last entry date on the patient’s record. 6 years as stipulated by HIPAA.
Disctrict of Columbia § 3–1210.11. Adult patients: : 3 years after last seeing the patient. Minor patients: 3 years after last seeing the patient or 3 years after patient reaches the age of 18 10 years following the date of discharge
Florida FLA. ADMIN. CODE ANN. r. 64B8-10.002 5 years from the last patient contact. Public hospitals: 7 years after the last entry.
Georgia GA. COMP. R. & REGS. § 111- 8-40-.18 10 years from the date the record item was created. Adult patients: 5 years after the date of discharge. Minor patients: 5 years past the age of majority (i.e., until patient turns 23).
Hawaii HAW. REV. STAT. § 622-58 Adult patients: Full medical records: 7 years after last data entry. Basic information: 25 years after the last record entry. Minor patients: Full medical records: 7 years after the patient reaches the age of majority (i.e., until patient turns 25). Basic information: 25 years after the minor reaches the age of majority. Adult patients: Full medical records: 7 years after last data entry. Basic information: 25 years after the last record entry. Minor patients: Full medical records: 7 years after the minor reaches the age of majority (i.e., until patient turns 25). Basic information: 25 years after the minor reaches the age of majority (i.e., until patient turns 43).
Idaho IDAHO CODE ANN. § 39- 1394 6 years as stipulated by HIPAA. Clinical laboratory test records and reports: 5 years after the date of the test.
Illinois 210 ILL. COMP. STAT. § 85/6.17 6 years as stipulated by HIPAA 10 years.
Indiana IND. CODE § 16-39-7-1 7 Years. 7 Years.
Iowa IOWA ADMIN. CODE R. 653-13.7(8) Adult patients: 7 years from the last date of service. Minor patients: 1 year after the minor attains the age of majority (i.e., until patient turns 19). 6 years as stipulated by basic HIPAA regulations.
Kansas KAN. ADMIN. REGS. § 28- 34-9a 10 years from when professional service was provided. Adult patients: Full records: 10 years after the last discharge of the patient. Minor patients: Full records: 10 years or 1 year beyond the date that the patient reaches the age of majority.
Kentucky 902 KY. ADMIN. REGS. 20:275 6 years as stipulated by basic HIPAA regulations. Adult patients: 5 years from date of discharge. Minor patients: 5 years from date of discharge or 3 years after the patient reaches the age of majority.
Louisiana LA. REV. STAT. ANN.§ 40:1165.1 6 years from the date a patient is last treated. 10 years from the date a patient is discharged.
Maine 22 MRS §1711 6 years as stipulated by basic HIPAA regulations. Adult patients: 7 years. Minor patients: 6 years past the age of majority. Patient logs and written x-ray reports— permanently.
Maryland MD. CODE REGS. §10.01.16.04 Adult patients: 5 years after the record or report was made. Minor patients: 5 years after the report or record was made or until the patient reaches the age of majority plus 3 years. Adult patients: 5 years after the record or report was made. Minor patients: 5 years after the report or record was made or until the patient reaches the age of majority plus 3 years.
Massachusetts 243 MASS. CODE REGS. § 2.07 Adult patients: 7 years from the date of the last patient encounter. Minor patients: 7 years from date of last patient encounter or until the patient reaches the age of 9. 30 years after the discharge or the final treatment of the patient.
Michigan MICH. COMP. LAWS § 333.16213 7 years from the from the date of the patient’s discharge or last treatment. 7 years from the from the date of the patient’s discharge or last treatment.
Minnesota MINN. STAT. § 145.32 6 years as stipulated by HIPAA Most medical records: Permanently (in microfilm). Miscellaneous documents: Adult patients: 7 years. Minor patients: 7 years following the age of majority.
Mississippi MISS. CODE ANN. § 41-9- 69 6 years as stipulated by basic HIPAA regulations. Adult patients: Discharged in sound mind: 10 years. Discharged at death: 7 years.(2) Minor patients: For the period of minority plus 7 years.(3)
Missouri MO. REV. STAT. § 334.097 7 years from the date the last professional service was provided. Adult patients: 10 years. Minor patients: 10 years or until patient’s 23rd birthday, whichever occurs later.
Montana MONT. CODE ANN. § 50-16-513 and MONT. CODE ANN. § 50-16-513 6 years as stipulated by HIPAA. Adult patients: Entire medical record—10 years following the date of a patient’s discharge or death. Minor patients: Entire medical record—10 years following the date the patient either attains the age of majority (i.e., until patient is 28) or dies, whichever is earlier. Core medical record must be maintained at least an additional 10 years beyond the periods provided above.
Nebraska 175 NEB. ADMIN CODE §9-006 6 years as stipulated by basic HIPAA regulations. Adult patients: 10 years following a patient’s discharge. Minor patients: (under 19) 10 years or until 3 years after the patient reaches age of majority (i.e., until patient turns 22), whichever is longer.
Nevada NEV. REV. STAT. § 629.051 5 years after receipt or production of health care record. 5 years after receipt or production of health care record.
New Hampshire N.H. CODE ADMIN. R. ANN. He-P 802.20 7 years from the date of the patient’s last contact with the physician, unless the patient has requested that the records be transferred to another health care provider. Adult patients: 7 years after a patient’s discharge. Minor patients: 7 years or until the minor reaches age 19, whichever is longer.
New Jersey N.J. STAT. ANN. § 26:8-5 7 years from the date of the most recent entry. Adult patients: 10 years following the most recent discharge. Minor patients: 10 years following the most recent discharge or until the patient is 23 years of age, whichever is longer. Discharge summary sheets (all) 20 years after discharge.
New Mexico N.M. CODE R. § 16.10.17.10 Adult patients: 2 years beyond what is required by state insurance laws and by Medicare and Medicaid requirements. Minor patients: 2 years beyond the date the patient is 18 (i.e., until the patient turns 20). Adult patients: 10 years following the last treatment date of the patient. Minor patients: Age of majority plus 1 year (i.e., until the patient turns 19).
New York N.Y. COMP. CODES R. & REGS. § 405.10 Adult patients: 6 years. Minor patients: 6 years and until 1 year after the minor reaches the age of 18 (i.e., until the patient turns 19). N.Y. Education § 6530 (2008) (providing retention requirements in the definitions for professional misconduct of physicians). Adult patients: 6 years from the date of discharge. Minor patients: 6 years from the date of discharge or 3 years after the patient reaches 18 years (i.e., until patient turns 21), whichever is longer. Deceased patients At least 6 years after death.
North Carolina 10A N.C. ADMIN. CODE §13B.3903 6 years as stipulated by basic HIPAA regulations. Adult patients: 11 years following discharge. Minor patients: Until the patient’s 30th birthday.
North Dakota N.D. ADMIN. CODE § 33-07-01.1-20 6 years as stipulated by basic HIPAA regulations. Adult patients: 10 years after the last treatment date. Minor patients: 10 years after the last treatment date or until the patient’s 21st birthday, whichever is later.
Ohio None 6 years as stipulated by HIPAA 6 years as stipulated by HIPAA
Oklahoma OKLA. ADMIN. CODE §310:667-19-14 6 years as stipulated by basic HIPAA regulations. Adult patients: 5 years beyond the date the patient was last seen. Minor patients: 3 years past the age of majority (i.e., until the patient turns 21). Deceased patients 3 years beyond the date of death.
Oregon OAR 333-505-0050 6 years as stipulated by basic HIPAA regulations. 10 years after the date of last discharge. Master patient index—permanently.
Pennsylvania 28 PA. CODE § 115.23 Adult patients: At least 7 years following the date of the last medical service. Minor patients: 7 years following the date of the last medical service or 1 year after the patient reaches age 21 (i.e., until patient turns 22), whichever is the longer period. Adult patients: 7 years following discharge. Minor patients: 7 years after the patient attains majority(5) or as long as adult records would be maintained.
Puerto Rico None 6 years as stipulated by HIPAA. 6 years as stipulated by basic HIPAA.
Rhode Island 230-RICR-20-60-4 5 years unless otherwise required by law or regulation. Adult patients: 5 years following discharge of the patient. Minor patients: 5 years after patient reaches the age of 18 years (i.e., until patient turns 23).
South Carolina S.C. CODE ANN. § 44-115-120 Adult patients: 10 years from the date of last treatment. Minor patients: 13 years from the date of last treatment. Adult patients: 10 years. Minor patients: Until the minor reaches age 18 and the "e;period of election"e; expires, which is usually 1 year after the minor reaches the age of majority (i.e., usually until patient turns 19).
South Dakota S.D. Codified Laws § 36-4-38 When records have become inactive or for which the whereabouts of the patient are unknown to the physician. Adult patients: 10 years from the actual visit date of service or resident care. Minor patients: 10 years from the actual visit date of service or resident care or until the minor reaches age of majority plus 2 years (i.e., until patient turns 20), whichever is later.
Tennessee Tenn. Comp. R. & Regs. 0880-02-.15 Adult patients: 10 years from the provider’s last professional contact with the patient. Minor patients: 10 years from the provider’s last professional contact with the patient or 1 year after the minor reaches the age of majority (i.e., until patient turns 19), whichever is later. Adult patients: 10 years following the discharge of the patient or the patient’s death during the patient’s period of treatment within the hospital. Minor patients: 10 years following discharge or for the period of minority plus at least one year (i.e., until patient turns 19), whichever is later.
Texas 22 TEX. ADMIN. CODE § 165.1 Adult patients: 7 years from the date of the last treatment. Minor patients: 7 years after the date of the last treatment or until the patient reaches age 21, whichever date is later. Adult patients: 10 years after the patient was last treated in the hospital. Minor patients: 10 years after the patient was last treated in the hospital or until the patient reaches age 20, whichever date is later.
Utah UTAH ADMIN. CODE §432-100-33 6 years as stipulated by HIPAA. Adult patients: 7 years. Minor patients: 7 years or until the minor reaches the age of 18 plus 4 years (i.e., patient turns 22), whichever is longer.
Vermont 12-5-14 VT. CODE R. §946 6 years as stipulated by HIPAA. 10 years.
Virginia 18 VA. ADMIN. CODE § 85-20-26 & 12 VA. ADMIN. CODE § 5-410-370 Adult patients: 6 years after the last patient contact. Minor patients: 6 years after the last patient contact or until the patient reaches age 18 (or becomes emancipated), whichever time period is longer. Adult patients: 5 years following patient’s discharge. Minor patients: 5 years after patient has reached the age of 18 (i.e., until the patient reaches age 23).
Washington WASH. REV. CODE § 70.41.190 6 years as stipulated by basic HIPAA regulations. Adult patients: 10 years following the patient’s most recent hospital discharge. Minor patients: 10 years following the patient’s most recent hospital discharge or 3 years after the patient reaches the age of 18 (i.e., until the patient turns 21) whichever is longer.
West Virginia H. B. 4396 6 years as stipulated by HIPAA. 6 years as stipulated by HIPAA.
Wisconsin WIS. ADMIN. CODE DHS Med 21.03 5 years from the date of the last entry in the record. 5 years.
Wyoming WYO. STAT. ANN. § 35-2-606 6 years as stipulated by HIPAA. 6 years as stipulated by HIPAA.

Source:
https://www.healthit.gov/sites/default/files/appa7-1.pdf

Important: The information contained within this page is provided as a reference with the understanding that this page and all authors of content, are not rendering legal information or advice. The information provided about state medical record retention laws is accurate to the date of publication and subject to change frequently. For more information on any law, consult your states official website.

Best Practices for Medical Records Retention

Develop a Comprehensive Medical Records Retention Policy

A well-crafted medical records retention policy is essential for healthcare organizations. This policy should outline the retention periods, storage methods, and destruction procedures for various types of records, taking into account federal and state regulations.

Implement Robust Security Measures

To ensure HIPAA compliance and protect patient data, healthcare providers must implement robust security measures for both electronic and paper-based records. These may include:

  1. Access Controls: Limit access to medical records to authorized personnel only, using unique user IDs and strong passwords.
  2. Data Encryption: Encrypt ePHI during storage and transmission to protect against unauthorized access or data breaches.
  3. Physical Security: Implement measures like locked storage rooms, security cameras, and alarm systems to safeguard paper-based records.

Regularly Audit and Monitor Records

Conduct regular audits and monitoring to identify potential issues or areas for improvement in your medical records retention processes. This includes reviewing your organization’s adherence to retention periods, evaluating storage conditions, and ensuring the secure disposal of expired records.

Train Staff on Medical Records Retention and HIPAA Compliance

Training staff on HIPAA compliance and medical records retention is essential for maintaining a secure and compliant healthcare environment. Regular training sessions can help employees understand their responsibilities and the importance of adhering to policies and procedures.

Establish a Document Destruction Process

Proper disposal of expired medical records is crucial to prevent unauthorized access and maintain patient privacy. Develop a secure and compliant document destruction process that includes:

  1. Shredding: Paper-based records should be cross-cut shredded to ensure the information is unreadable and irrecoverable.
  2. Electronic Deletion: Securely delete electronic records using data wiping software that overwrites the data multiple times.
  3. Third-Party Destruction: If utilizing a third-party shredding service, ensure they adhere to HIPAA regulations and provide a Certificate of Destruction upon completion.

Key Components of an Effective Medical Record Retention Policy

An effective medical record retention policy should include the following components:

  1. Purpose: Clearly define the goals and objectives of the policy, such as compliance with applicable laws and organizational efficiency.
  2. Scope: Specify which records the policy applies to, including paper, electronic, and other media types.
  3. Responsibilities: Assign responsibility for policy implementation and enforcement to specific individuals or departments.
  4. Retention Periods: Establish retention periods for each record type, based on legal requirements and operational needs.
  5. Storage and Preservation: Outline the procedures for secure storage and preservation of records during their retention period.
  6. Destruction: Detail the methods and processes for securely destroying records once their retention period has expired.

How To Create and Implement a Medical Record Retention Schedule

A record retention schedule serves as a roadmap for determining how long records should be retained and when they should be destroyed. Follow these steps to create and implement an effective record retention schedule:

  1. Inventory: Conduct a comprehensive inventory of all records held by the organization, including their format and location.
  2. Categorize: Organize records into categories based on their function, content, or regulatory requirements.
  3. Research: Identify federal, state, and industry-specific regulations governing record retention and destruction.
  4. Establish Retention Periods: Determine the appropriate retention period for each record category, taking into account legal requirements and organizational needs.
  5. Document: Create a written retention schedule, clearly outlining the retention periods and destruction procedures for each record category.
  6. Train and Communicate: Train staff on the record retention schedule and ensure that it is effectively communicated throughout the organization.
  7. Monitor and Update: Regularly review and update the retention schedule to reflect changes in regulations, industry standards, and organizational needs.

Secure and Compliant Record Destruction

To ensure the secure and compliant destruction of records, healthcare organizations should adhere to the following best practices:

  1. Develop a Destruction Policy: Create a written policy outlining the methods and processes for securely destroying records, including the individuals or departments responsible for overseeing the process.
  2. Select Appropriate Destruction Methods: Choose destruction methods that render the records unreadable, indecipherable, and irretrievable. Common methods include shredding, incineration, and degaussing for electronic media.
  3. Establish a Chain of Custody: Implement a secure chain of custody procedure to track records from the point of collection to final destruction, ensuring accountability and reducing the risk of unauthorized access.
  4. Conduct Regular Audits: Regularly audit the record destruction process to verify compliance with the destruction policy and applicable regulations.
  5. Obtain a Certificate of Destruction: Upon completion of the destruction process, obtain a certificate of destruction from the service provider or internal department responsible for the task. This document serves as evidence of compliance with legal and regulatory requirements.
  6. Update the Retention Schedule: After records have been securely destroyed, update the retention schedule to reflect their disposal and maintain accurate documentation.

The Role of Electronic Health Records (EHR) in Medical Records Retention

The adoption of Electronic Health Records (EHR) systems has significantly impacted medical records retention over the last decade. EHRs offer numerous benefits in terms of efficiency, accessibility, and security over paper records systems, making them an invaluable tool for healthcare organizations.

Advantages of EHR in Medical Records Retention

  1. Streamlined Access: EHR systems allow healthcare providers to access patient records quickly and easily, improving collaboration and continuity of care.
  2. Enhanced Security: With features like access controls, audit trails, and encryption, EHR systems offer robust security measures to protect sensitive patient data.
  3. Automated Retention: EHR systems can be configured to automate retention periods and deletion processes, ensuring compliance with federal and state regulations.

Selecting an EHR System for Your Healthcare Organization

When choosing an EHR system, consider factors such as:

  1. HIPAA Compliance: Ensure the EHR system adheres to HIPAA regulations and provides necessary security features to safeguard PHI.
  2. Interoperability: Evaluate the system’s ability to communicate and exchange information with other healthcare systems, facilitating seamless coordination between providers.
  3. Customization: Select a system that can be tailored to your practice’s specific needs and workflows, improving efficiency and user satisfaction.

Migrating to an EHR System: A Seamless Transition for Medical Practices

The process of migrating from traditional paper-based medical records to an Electronic Health Records (EHR) system can be a complex yet rewarding endeavor for medical practices.

To ensure a smooth transition, organizations should start by creating a detailed migration plan that outlines the necessary steps and timelines. Begin by assembling a dedicated team comprising representatives from various departments, including IT, administration, and clinical staff, to oversee and manage the migration process. Next, evaluate and select an EHR system that meets your organization’s specific requirements, as discussed in the previous section.

Once the system is chosen, initiate staff training on the new EHR to promote user adoption and minimize disruption to daily operations.

The actual migration process involves transferring existing patient records to the new system, which can be done through manual data entry, a medical records scanning service, or leveraging data conversion tools. Ensuring data accuracy and integrity during this step is crucial, so be prepared to allocate sufficient time and resources for thorough data validation.

After the migration is complete, establish a period of parallel operation where both paper and electronic records are maintained, allowing your team to verify the accuracy and completeness of the transferred data before fully transitioning to the EHR system. By following these guidelines and adopting a well-structured approach, medical practices can successfully migrate to an EHR system, reaping the benefits of improved efficiency, enhanced patient care, and streamlined medical records retention.

What comes next?

Effective record retention and destruction practices are crucial for healthcare organizations to ensure legal compliance, safeguard patient information, and maintain operational efficiency. By implementing a comprehensive record retention policy and schedule, as well as adhering to best practices in secure record destruction, healthcare organizations can reduce risks, protect sensitive data, and fulfill their obligations to patients and regulatory authorities.

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