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When medical records are eligible for destruction, they can be shredded (and recycled) or burned. Here are some guidelines to follow:
- Maintain records that are scheduled for destruction in a secure location to guard against unauthorized or inappropriate access until the destruction is complete.
- Whether you shred the records yourself in your office or hire a record destruction company, create a permanent record destruction log, individually listing all medical records with the following information:
- Patient name and medical record number (or other identifier);
- Date of destruction, combined with a notation that the record was destroyed in accordance with the retention policy; and
- Signature of staff person performing the destruction, or if you are using a record destruction company, the name of the company and signature(s) of individuals witnessing the destruction. (Add signatures after the destruction has been completed.)
Also, if you use an outside company,
- Make sure the destruction contract specifies the method of destruction and time to elapse between acquisition and destruction.
- Establish safeguards for confidentiality.
- Follow the record destruction company’s protocol for carrying out the actual destruction.
- Obtain a certificate of destruction from the company and file it with your log.
- Obtain a statement that records were destroyed in the normal course of business.
- Indemnify your practice from loss due to unauthorized disclosure.
Note: Medical records are eligible for destruction in a minimum of seven years from the anniversary of the last date of treatment or, if the patient is a minor, seven years from the anniversary of the last date of treatment or until the minor reaches 21 (whichever is later). Do not destroy medical records that relate to any civil, criminal, or administrative proceeding if you know the proceeding has not been finally resolved. Follow any state and federal regulation that requires you to retain medical records longer than the above time periods. Read Retention of Medical Records (TMA members only) for more details.
TMA Knowledge Center reports it receives more questions from physicians and their staff about medical records than about any other topic. You can find valuable information in the TMA publication Medical Records: Your Rapid Route to Answers, available for purchase through the TMA Store.
NOTICE: Please check the Texas Medical Board Web site (www.tmb.state.tx.us) for current updates on its rules and policies with respect to this issue.
NOTICE: The Office of the General Counsel provides legal representation for TMA in its activities and assists county medical societies physicians and their attorneys and the public with questions regarding medical law. The Office of the General Counsel of the Texas Medical Association provides this information with the express understanding that 1) no attorney-client relationship exists, 2) neither TMA nor its attorneys are engaged in providing legal advice and 3) that the information is of a general character. You should not rely on this information when dealing with personal legal matters; rather legal advice from retained legal counsel should be sought.
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Last Published: 1/29/2010 Print this page
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