Maintaining up-to-date patient records is essential. Patient records help you monitor changes in your patients’ health and keep track of crucial information that allows you to provide the best possible practice. Also, as physicians, we’re bound by law to make those records available upon request. Over the years, the regulations have evolved and become more cumbersome.
Let’s review some of the common questions about patient records and ways to streamline your practice.
Is there a difference between electronic medical records (EMR) and electronic health records (EHR)?
Yes, there is a difference. While both are electronically captured and stored information, an EMR is a digital version of a patient’s chart, specific to your practice. It includes your patients’ medical history, diagnoses, and treatments. An EMR helps you track each patient’s data and provide reminders to book wellness checks and other preventive screenings.
EHR also hold medical data about patients, but they provide a more inclusive view of the patient’s medical history as the file is designed to be shared by all providers for a patient. They provide streamlined, up-to-date information about a patient in real time, giving you critical information about other aspects of their medical history including everything from their allergies to their radiology images.
In summary, you can share EHR with appropriate parties when requested, but EMR stay in your practice.
Do electronic medical records include financial information?
That actually depends on the regulations in your state. You should check with your state medical board and business attorney to confirm what billing and insurance information needs to be saved, especially in relation to Medicare and Medicaid patients.
How long do I need to store medical records?
States have different guidelines and laws on how long you should store patient records. For example, while the state of California has no statutory requirements, the California Medical Association recommends that practices retain records for at least 25 years or preferably indefinitely.
Check on what your state requires, but in general, we recommend that you hold on to adult records for 10 years after the last date the patient was seen. For minors, store the files for 28 years from the patient’s date of birth. If you have a patient that passes away, keep their medical records for 5 years after their date of death.
What are the storage requirements for patient records?
Your EHR should be compliant with HIPAA encryption and security regulations ensuring privacy, safety, and accessibility. You should transfer all records stored on less secure devices such as microfilm, microfiche, or disk onto your EHR. Without the need to store thousands of pages of paper records, you can hold on to information about your patients indefinitely.
You should also back up your EHR as recommended and safe a copy of the software to ensure your patient records can be retrieved and read in the future.
Do I need to keep copies of X-rays?
Yes, you need to keep videos, x-ray films, EKGs, fetal monitor strips, and photos. Any diagnostic, clinical, or demographic data collected during an appointment is part of the medical/legal document.
If a patient brings his or her past medical records to my office, am I required to maintain all of the copies?
You don’t need to keep copies of everything, but you should review the records and extract and copy any information that you might need before returning the documents to the patient. Then you can incorporate any copied data into the patient’s permanent office record. The reason that you don’t keep all of the patient’s records is that you may be held liable for information related to other specialties.
Who is allowed to request patient records?
HIPAA gives patients the right to request copies of their medical records. However, HIPPA also includes strict privacy guidelines about who can receive a copy of an individual’s medical records. In almost all cases, only the patient or their designated representative may request a copy of the patient’s medical records. The patient needs to have completed a release of information to identify a specific person as a representative. In some states, a person with health care power of attorney can request records as a representative.
What should I do if someone claiming to be a relative of a deceased patient requests a copy of their records?
First, confirm that the patient is deceased, either by checking your own medical records or by requesting a death certificate. Then, you need to confirm that the requestor is a legitimate representative of the deceased patient’s estate. Once both facts have been confirmed, you can provide a copy of the patient’s records to the requestor.
Even if a patient has passed away, first you need to confirm that the patient is deceased and the requestor must provide an official document from the state showing that they are the patient’s executor or another qualified representative.
How much time is my staff going to spend on patient record requests?
The short answer? Too much. Even if you have a staff member who can manually complete responses to four patient records requests in an hour, that’s still taking their time away from patient care and other more profitable administrative tasks.
What is the opportunity cost of patient record requests?
The opportunity cost is the income you are missing out on by having a member of your staff respond to patient record requests manually. The most significant cost associated with patient record retrieval is your employee’s time. Assuming you pay your staff $16 per hour, and they can process four patient record requests in an hour, that means at $6.50 per request, you’re bringing in $26 for those requests, netting you $10 for the hour.
While making $10 is fine, it’s not going to help pay down your mortgage or pad your retirement fund, let alone make you rich. But if your employee used that hour to call patients to encourage them to book their annual wellness visit, they could generate a lot more income for your practice. For example, if your employee manages to talk to six patients in an hour and schedule four appointments, at an average insurance payout of $150, they could generate $600 in income in the same amount of time that they would have spent on responding to patient record requests.
How can I save time on patient record requests?
We developed e-Paper Road to automate responses to patient record requests. This innovative software takes the work out of responding to patient requests. When someone makes a request, your office staff simply directs them to a website, where they log on and provide proof of identification. Our software accesses your EHR system via a secure, encrypted connection to pull the appropriate records and deliver them to the requestor. Your team can then spend their time on more important and valuable tasks.
(updated January 2020)