Assignment:
Where did all the paper files go?
Some health care facilities retain medical records longer than state and federal retention laws require. The dilemma for these facilities is where the "inactive" records will be stored since space is a valued commodity. Reflect on your readings and experience and post your thoughts on what you think would be the best storage option in terms of cost and value to the organization. An example recommendation could be to store the "inactive" off-site. Defend why you chose this option? Explain how the records will be retrieved when requested? Explain how you plan to propose the retention plan for the "inactive" records to administration. You must cite any resources that you utilize.
Read the following article
Retention and Destruction of Health Information (2013 update)
Medical records have evolved through time because of accreditation agencies as well as Medicare and Medicaid rules and individual facility policies, including medical staff rules. In the beginning, all documentation was done on paper. How long the paper was kept was not a concern because there was room for storage, and the documentation requirements were not as extensive as they are today. The rule of thumb in documentation is if it was not documented, it was not done to the patient. It is very important that a facility have a record retention policy and archival options to cover not only medical records but also other important papers like minutes of meetings, older policies that may be needed in the future, and quality assurance reviews.
Twenty years ago, when file rooms were getting low on space, the paper medical records were converted to microfilm or microfiche as an archival option. These films took up much less space than the paper files. This process worked well for many years and saved on storage.
As time went on and different types of storage were developed, disks and scanning of records were also used for record storage. With the implementation of computerized reports such as in the laboratory and radiology, the size of the paper medical record became larger. Gone were the small slips of paper that gave test results when the computerized programs were implemented, and these turned into one page for one report. This made the medical records larger in size, and file rooms became packed with paper medical records.
The health record is kept for patient care but also for legal issues for the facility. This may result in keeping the original medical records for a longer period of time. Many hospital attorneys need records kept to defend medical malpractice cases and other legal cases. A legal health record policy is a needed policy for any facility that has electronic medical records where components of the health record need to be designated as permanent documents.
The down side of keeping older records that are stored on different medium is the fact that it is difficult to purchase parts for microfilm readers, microfiche reader, and printers. Archival options need to be considered when developing a record retention policy, and consideration needs to be given to how long to keep this data. Hospital attorneys need to be consulted because they are aware of pending law suits and how long records need to be kept for this consideration.
Today many medical record file areas do have older records and one will find many file rooms that contain inactive records. There are facilities that opt to pay a record storage company outside of the facility to store these inactive records. There are many vendors that will keep and store these records for a fee. It is always a good plan to investigate the security of the storage and the ease of retrieving files when needed. The price is a factor but there are times when you pay for what you receive.
When records become electronic, the paper storage records do not go away immediately. Paper is still used in many facilities that do a scanning process of the records, and a policy needs to be written to cover how long to keep these records after the scanning has been done and verified. Recommendations vary on this process -- anywhere from 30 to 120 days. Again, this needs to be determined by site specific comfort level because the electronic record will become the official or "legal medical record."