Medical Record Retention
Does ASHA specify how long an SLP must maintain patient records?
No, ASHA does not have a policy on record retention. Each state may have unique medical record retention laws that vary by setting or type of record. In addition, federal law (HIPAA), payers, and regulatory or accrediting agencies may have regulations governing record retention. It is advisable to know all applicable regulations and abide by the most stringent.
How long must I keep records if I am a HIPAA covered entity?
The Office of Civil Rights indicates that HIPAA regulations do not include medical record retention requirements. Instead, the laws in your state regarding record retention would apply. HIPAA rules do require that you apply appropriate administrative, technical, and physical safeguards to protect the privacy of information for as long as you maintain records. There is a 6 year retention period for HIPAA policies and procedures.
What are Medicare's requirements for record retention?
The Centers for Medicare and Medicaid Services (CMS) requires that patient records for Medicare beneficiaries be retained for a period of 5 years (see 42CFR482.24 (b) [PDF]). Medicaid requirements may vary by state.
Additional information about record retention rules [PDF] are available from CMS.
How can I find the record retention laws for my state?
Laws regarding record retention are passed by the state legislature. You can search your state's Web site to find applicable laws or try searching your state's Department of Health Web site. If you work in a facility with a medical records department, talk with them about applicable laws and regulations. You can also contact a lawyer knowledgeable about federal and state medical record laws.
Yo aur state licensure board may have issued guidance about record retention. For example, the New York Office of the Professions includes information about record retention in their Frequently Asked Practice Questions and Practice Guidelines.
Some organizations have developed state-by-state summaries of record retention laws. ASHA cannot attest to the currency of the following resources:
In addition, the American Health Information Management Association (AHIMA) has created a summary federal health record retention requirements [PDF].
Are recordings of instrumental swallowing or voice evaluations considered part of the medical record?
The answer to this question is not clear cut. ASHA does not have a policy that requires that video or digital images be kept as part of the medical record.
Other organizations have addressed this issue to varying degrees. The American College of Radiology (ACR) has developed suggestions and rationales around record retention. In the Digest of Council Actions 1997-2006, the ACR suggests that, unless otherwise specified by statute, the term "medical records" includes "radiographs and other images produced in the course of radiological examinations." This paper also says that "...hospitals participating in Medicare have to keep copies of reports, printouts, films, scans, and other images for at least five years." State and other federal regulations, such as HIPAA, may have more stringent regulations.
In the section on magnetic tapes of Appendix E, the ACR says that "magnetic tapes containing the digital versions of MRI or CT studies are not permanent "medical records" and do not have to be retained for the statutory or recommended retention periods as long as a hard copy of the image is placed in the patient's permanent file."
The American Health Information Management Association (AHIMA) has a document about legal health records. They indicate that diagnostic images and radiology films are considered part of the legal health record.
As with paper or electronic records, the first place to start any search for your state's regulations about digital or video images is the state department of health. If no specific information is available, it may be a matter of interpreting the regulations about x-ray films or other radiological images. Check with your medical records or radiology departments to find out what the current regulations are in your state.