The Importance of Retention Policy
Health record retention policies establish how long different types of records must be kept before they may be legally destroyed, balancing legal, regulatory, clinical, and operational needs against the costs and risks of maintaining records indefinitely. Retention policy development requires careful research into applicable federal and state requirements.
Federal Retention Requirements
Federal requirements vary by record type and program. Medicare Conditions of Participation generally require hospitals to retain medical records for at least five years, while state laws often impose longer retention periods that take precedence when more stringent. Records related to minors typically must be retained until the patient reaches the age of majority plus an additional statutory period, reflecting extended statutes of limitations for claims involving minors.
State Retention Requirements
State laws vary considerably and often specify different retention periods for adult records, minor records, and specific document types such as x-rays or fetal monitoring strips. HIM professionals must research the specific requirements of every state in which their organization operates and apply the most stringent applicable requirement when multiple jurisdictions or regulations intersect.
Factors Influencing Retention Schedules
- State statutes of limitations for medical malpractice claims
- Federal program participation requirements, such as Medicare and Medicaid
- Record type, such as adult versus minor patient records
- Organizational risk tolerance and legal counsel guidance
- Historical, research, or educational value of specific records
Legal Holds
When litigation is reasonably anticipated or has been initiated, organizations must suspend normal destruction schedules for any records potentially relevant to the matter, a legal obligation known as a litigation hold or legal hold. Failure to preserve records under an active legal hold can result in spoliation sanctions, including adverse inference instructions against the organization in court.
Destruction Methods
When retention periods expire and no legal hold applies, records may be destroyed using methods appropriate to their format. Paper records typically require cross-cut shredding, pulping, or incineration, while electronic records require secure deletion methods that render data unrecoverable, such as degaussing magnetic media or cryptographic erasure for encrypted storage.
Documentation of Destruction
Organizations must maintain a certificate of destruction or equivalent documentation recording what records were destroyed, the destruction method used, the date of destruction, and authorization for the destruction. This documentation provides evidence of compliant, policy-driven destruction rather than improper or premature record disposal.