AHIMA's Long-Term Care Health Information Practice & Documentation Guidelines
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Retention
Contents
HIM STANDARD:
- The healthcare organization’s and health information management department’s health record and data retention systems, policies, procedures, and specified periods of retention comply with federal and state regulations; certification, licensure and accepted standards of practice.
- The retention system is designed and implemented to ensure the safety, security, and accuracy of health records and resident-identifiable data, and it considers the needs of all legitimate users of health records and resident-identifiable data.
- Health information management department provides assistance to other departments in developing retention schedules for their records, data, indexes, and reports.
Facility policy should define a specific retention schedule for different types of records based on federal and state law and professional practice standards. The policy should be consistently applied and records destroyed after the retention period has expired. Storage areas should be organized and storage boxes labeled with the content, year of documents, and year records/documents can be destroyed.
Retention Guidelines
The following retention schedule outlines federal guidelines and recommended retention guidelines. If State law requires a different retention period, the more stringent between federal and state must be followed. After considering the required retention period, every facility should define in policy their specific retention period not to be less than the period defined by state or federal law.
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Document Type
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Federal Regulation
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State Regulations
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AHIMA Recommended Guideline
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Health Record
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(F515) 5yrs after discharge when there is no requirement by state law; For minors, 3 years after the resident reaches legal age as defined by state law. Medicare residents – 5 years after the month the cost report is filed (CMS Skilled Nursing Facility Manual – Pub 12)
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See Exhibit A AHIMA Practice Brief Table 4: State Laws or Regulations Pertaining to Retention of Health Information
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10 years based on False Claims Act (31 USC 3729-3733)
Section 3731: Statute of Limitations; a claim of fraud can be made up to 10 years from the date of violation, materials must be made available for inspection which includes financial and health records
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Financial Record
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Medicare residents – 5 years after the month the cost report is filed. (CMS Skilled Nursing Facility Manual – Pub 12)
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Refer to above recommendation 10 year retention period
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Master Patient Index
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Permanent
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Admission/Discharge Register
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Permanent
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OSHA Records/ Employee Medical Records
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Duration of employment plus 30 years
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HIPAA Related Documents (i.e. Accounting of Disclosure, Request for Amendment, Requested Restrictions, etc.)
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6 years (HIPAA Privacy Rule) or length of record retention if documents kept in the medical record – whichever is longer
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