Why Retention Policies Matter
Record retention policies determine how long health records and related data must be kept before they can be destroyed. RHIA candidates must understand that retention requirements are shaped by a combination of state law, federal regulation, payer requirements, and organizational risk tolerance, meaning there is no single universal retention period.
Factors Influencing Retention Periods
- State statutes of limitations for medical malpractice claims
- Minor patient considerations, often extending retention until the age of majority plus additional years
- Medicare and Medicaid conditions of participation requiring minimum retention periods
- Research record requirements tied to institutional review board obligations
Because these requirements vary, HIM professionals typically consult legal counsel and reference state-specific retention guidelines when developing a retention schedule.
Developing a Retention Schedule
A retention schedule should catalog every record type the organization maintains, including diagnostic images, laboratory reports, billing records, and any legacy paper records not yet converted to electronic form. Each record type is assigned a minimum retention period along with a designated method of destruction once that period expires.
Destruction Methods and Documentation
Proper destruction must render information permanently unreadable and unrecoverable, whether through shredding for paper or secure wiping for electronic media. Organizations must document destruction activities, including the date, method, and records destroyed, to demonstrate compliance if questioned later.
Legal Holds
A retention schedule must always be subordinate to legal hold requirements. When litigation is reasonably anticipated or already underway, any records related to that matter must be preserved regardless of the standard retention schedule, and destruction of those records must be suspended immediately.
Retention in Hybrid and Electronic Environments
Organizations transitioning from paper to electronic records must ensure that retention policies address both formats consistently, particularly during the transition period when some records exist only in legacy paper form and others exist only electronically.
Exam Tips
Expect questions asking you to identify the appropriate retention period based on state-specific scenarios and to recognize the interaction between legal holds and standard retention schedules. Understand that the HIM professional plays a central role in developing, communicating, and enforcing retention policy across the organization.