Proper documentation and record-keeping practices help protect patients and the ability to practice effective healthcare. Accordingly, the HIPAA Act includes record retention as one of its compliance requirements. Understanding and having a retention policy helps healthcare organizations demonstrate HIPAA compliance, prevent HIPAA violations, and avoid breaches of protected health information (PHI).
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HIPAA rules on documentation retention
HIPAA, the Health Insurance Portability and Accountability Act of 1996, protects the rights and privacy of patients. The act was created to improve health coverage standards and combat fraud and abuse related to PHI. While not explicitly stated within the guidelines, HIPAA does include information about retaining records.
The Privacy Rule establishes a framework for documentation retention in healthcare organizations. Generally, the Security Rule focuses on electronic PHI (ePHI) record keeping. The HIPAA Administrative Simplification regulations include several references to data retention in two categories: HIPAA medical records retention and HIPAA records retention requirements.
In a sense, there are no HIPAA medical records retention requirements though requirements do exist for other types of documentation such as:
- Policies and procedures
- Complaints
- Dispositions
- Security Rule assessments
- Breach notification records
Furthermore, organizations should retain documents related to incident responses and any other actions taken to ensure HIPAA compliance. Health practitioners must retain these records for six years from their creation date or the date they were last in effect. Maintaining records beyond the minimum required period is advisable to meet potential legal, operational, or clinical issues.
SEE ALSO: What is the retention period for medical records under HIPAA?
State retention requirements
The lack of a medical record retention mandate can be confusing since individuals can access information for as long as their information is maintained. Generally, healthcare organizations must provide an accounting for the six years before request. In short, there is no mandated HIPAA medical record retention period because states have their own requirements. HIPAA does not preempt state retention laws.
States’ retention periods vary depending on the nature of the records and who they belong to. Some states require providers to retain records for as little as three years while others maintain up to 10 years or longer. Some states also explore requirements for how records should be stored. HIPAA doesn’t necessarily provide specific storage requirements but does include language about keeping records secure from breaches.
Why a HIPAA retention policy
HIPAA requires covered entities and business associates to have retention policies in place to prevent the unnecessary disclosure of PHI. A good retention policy also:
- Ensures HIPAA compliance with record-keeping
- Mitigates risks
- Safeguards patient privacy
- Protects organizational integrity
- Provides legal defense (in case of a breach)
- Supports audits, investigations, and legal proceedings
A strong retention policy maintains data integrity and accuracy by ensuring the availability of up-to-date patient health information. It also facilitates patients’ rights and access to their health information, promoting transparency and trust between patients and healthcare providers.
What should be included in a retention policy?
Like all suitable HIPAA policies, a record retention policy should be comprehensive and clear, outlining how to handle, access, share, and store PHI. The following information must be included:
- The storage of specific records and documents
- A method for monitoring access and activities related to records
- An outline of timeframes for keeping certain documentation
- How employees interact and use records
- Clear protocols for proper disposal and destruction of data
- Clear guidelines on auditing retention policies
- Strategies for archiving and data recovery in case of an emergency
Finally, a retention policy should establish a document retention schedule tailored to individual organizations, HIPAA, and state regulations.
Retention policies and data storage security
While data security and storage are not explicit when it comes to data retention, such security is vital to HIPAA compliance. Data storage should be added to a good retention policy. Along with the above information, it is important to note where and how documentation should be stored securely.
Physical records containing PHI should be stored in locked cabinets or rooms with restricted access. Electronic records should be stored in secure systems with appropriate physical locks, cybersecurity, and regular data backups. Information should be protected with strong access controls (e.g., multifactor authentication) and perimeter defenses (e.g., firewalls).
Proper retention of records is an important component of HIPAA compliance. Implementing such features guarantees that only authorized personnel can access sensitive documents, safeguarding against unauthorized access or disclosure. Organizations should establish a retention policy that aligns with HIPAA and state laws.
FIND OUT MORE: Is cybersecurity a HIPAA requirement?
Kapua Iao
