Optometry Coding & Billing Alert

Why observing the 6-year federal requirement may not be adequate

Before you toss those records for patients your optometrist no longer treats, make sure you-ve satisfied your state's rules on records retention, or you could wind up in hot water. 

The rules for keeping the records of ex-patients vary by state. There are also different rules for underage-patient records--so unfortunately, there is no cut-and-dried answer to this dilemma.

Weigh the pros and cons of keeping medical records around for a long time.

Pro: You-ll be complying with state and federal guidelines by holding on to records for the proscribed time. Also, you-ll need those medical records if the practice is hit with a medical malpractice suit. For example, Patient A is suing Optometrist C for malpractice. If Dr. C's office cannot produce Patient A's medical record, the case is undisputable, meaning that Dr. C will lose.

Con: While keeping medical records in case of malpractice is a good idea, the records do pose a security risk until you destroy them.

-The longer you retain a set of records, the more chance there is that there can be an inadvertent disclosure [of the patient's information] or identity theft,- says Robert Hille, a healthcare attorney in Secaucus, N.J.

Minimum: Hold on to the records for at least six years--the federal minimum for records retention after the patient is last seen.

Know What Your State Requires

If you don't know your state statute on medical records retention, find out immediately.

Many states mandate that practices keep records longer than six years. And in this area, state law has more authority than federal statutes, Hille says.

In most states, the law says that you must keep records for seven to 10 years. In New Jersey, for instance, practices can dispose of records seven years after the patient is last seen.

Vermont's statute of limitations for medical malpractice is seven years, so Vermont medical offices must keep records for at least seven years after the patient is last seen.

Good idea: Even if your state mandates a seven-year minimum for retaining records, hold on to the records a little longer, experts say. For instance, the American Health Information Management Association (AHIMA) recommends practices keep records for a decade after the date the patient was last seen, regardless of the particular state regulation.

Smart: Line up your records retention policy with other area facilities, especially hospitals. At Mid-South Surgeons in Columbia, Tenn., they keep the records for as long as the local hospital does, -which is 10 years after the patient is last seen,- says office manager Laura Bassett.

Observe Special Rules for Minors

Rules governing medical records retention get a little trickier when you are dealing with minors. Pediatric practices must often keep records longer than the state mandate, because the law requires you to keep the records for a certain period of time after the patient reaches -adult- status, which could be anywhere from age 18 years to 21, depending on the state.

Strategy: Check your state regulations governing records retention of minors, and make sure you keep minors- records for at least as long as the state dictates, experts say.

-For minors, we keep records for 10 years after they reach the age of 18,- Bassett says.