Retention of Paper Medical Records After Converting to Electronic Health Records

191563_blog_medical%20RecordsNOTE: On February 18, 2010, we posted an article about what to do with paper medical records when converting to an electronic health record (EHR). To date, this has been the most popular article on the HITECH Law Blog. We decided to re-review the topic, update it, and repost it. Actually, not much has changed in the way of the law applicable to this topic. So, the article below reiterates most of the tips from our original article with a few refinements, including additional information about retention periods.

Many hospitals have electronic health records (EHRs) that are hybrid digital records. While the hospital may be using electronic data entry in the emergency department, inpatient nursing care, pharmacy, lab, and pre-op anesthesia, oftentimes, these EHRs are not integrated and, thus, are not merged into a single EHR. The short-term solution may have been to scan printed records from some department, like lab or pharmacy, into the patient’s on-line digital record. As a result, the hospital’s “electronic health record” contains information that is not captured in a “coded format.” For one, this will not meet the “meaningful use” criteria under the HITECH Act.

But let’s assume that the hospital can overcome this hurdle by working with vendors to integrate these records in a way that will meet HITECH EHR certification standards. If the hospital has been maintaining certain portions of patient records in a paper format, what does it do with those paper records after converting to an EHR? If the hospital scans all the paper patient records into its EHR, how long should the hospital retain the paper record after it is scanned into their EHR?

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Conversion to electronic health record and retention of paper records

Editor’s Note: Due to the continued popularity of this post, this article was reviewed and updated on September 30, 2013. For the later version, click here.

Update: On August 8, 2010, Medicare issued MLN Matters Article SE1022 on Medical Record Retention and Media Formats for Medical Records, which states that the Centers for Medicare and Medicaid Services (CMS) requires records of providers submitting cost reports (most hospitals) to be retained in their original or legally reproduced form (which may be electronic), for at least 5 years after closure of the cost report.

Many hospitals have electronic health records (EHRs) that are hybrid digital records. While the hospital may be using electronic data entry in the ER, inpatient nursing care, pharmacy, lab, and pre-op anesthesia, oftentimes, these EHRs are not integrated and, thus, are not merged into a single EHR. The short-term solution may have been to scan printed records from some department, like lab or pharmacy, into the patient’s on-line digital record. As a result, the hospital’s “electronic health record” contains information that is not captured in a “coded format.”  For one, this will not meet the Stage One “meaningful use” criteria under the HITECH Act.

But let’s assume that the hospital can overcome this hurdle by working with vendors to integrate these records in a way that will meet HITECH EHR certification standards.  If the hospital has been maintaining certain portions of patient records in a paper format, what does it do with those paper records after converting to an EHR?   If the hospital scans all the paper patient records into its EHR, how long should the hospital retain the paper record after it is scanned into their EHR? 

Continue reading