Medical Records Policy [Healthcare Compliance Tips]

Develop a medical record request and retention policy to address state and federal laws.

An article posted by HIPAA Journal shares the Dental Board of California revealed that most dentists are failing to provide patients copies of their dental records promptly, which is a violation of state and HIPAA law.

We know you don’t want to be the next practice subject to scrutiny.  Therefore, allow us to share a few HIPAA guidelines that medical and dental practices should follow, such as:

• Medical record documentation must be kept for at least six years from the date of creation. A best practice is to keep them longer, in case an investigation arises (10+ years).
• Requests must be provided within 30 days for onsite and 60 days off-site.
• Patients can’t be denied a copy of their records, even if their balance is unpaid.
• A reasonable charge may be accessed to the patient for copying or mailing records.
• No charge can be accessed for searching or retrieving the medical records.

Though uncommon, the Office of Civil Rights (OCR), which is under the Department of Health and Human Services (HHS), can enforce penalties for those that choose not to follow HIPAA regulations regarding medical record policies.

Therefore, we suggest that you develop a medical record retention policy to address state and federal requirements.

Also, to promote transparency, share a copy with your patient at their next visit.  Let them know you are ready and open to serve them when any medical record requests are submitted.

**The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify, and tailor the advice to fit your specialty.