Dental Records Retention and Destruction
Managing Records at a Dental Office
As with any business, document retention and destruction are two key factors in running a well-managed office. Managing a dental retention schedule and proper and timely destruction is critically important to avoiding excess accumulation of data, improving environmental impact, properly managing records, and securing protected health information.
The most common record-keeping errors, noted by the American Dental Association, include:
- Undocumented treatment plans
- Undocumented or not regularly updated health histories
- Undocumented patient assessment
Incomplete documentation and a lack of organization are the primary record-keeping errors found in dental offices. A written dental record-keeping policy and records retention schedule that is easily understood and followed by all staff, can help to keep records organized and ensure proper retention. In addition, dental offices can more easily and systematically identify records that need to be destroyed, which can clear space of unnecessary documents, allowing for easier management of all documents and help to avoid record-keeping errors. There are several guidelines that may be followed for efficient dental records retention. Follow these steps to keep your dental practice from avoiding errors in documentation and to remain regulation-compliant.
Create a Dental Records Retention Schedule
A document management policy outlines a protocol for handling secure documents, including creation, management and proper disposal. A detailed policy is crucial to maintain information security across your business. In the case of any information breach or damage control situation, the proper protocol should be detailed and understood by all employees.
A crucial element to the proper destruction of documents is a record retention schedule. Retention periods and disposal method may vary by location, but the general format of the calendar can be arranged with this template.
In the healthcare industry, any patient-specific documentation must be handled according to HIPAA requirements in order to ensure privacy and security. However, HIPAA does not regulate retention of medical or dental schedules; this is mandated state-by-state. To create a records retention schedule for your dental practice, refer to your state dental records retention policy below:
For patients using Medicare or Medicaid Services, records are required to be retained for at least five years for claims and billing purposes (as per The Centers For Medicare and Medicaid Services requires that Medicare and Medicaid).
For documents other than dental records, the following retention and destruction methods should be adhered to:
|Document Type||Retention Period||Disposal Method|
|Clinic appointment calendars||6 years||Shred|
|Clinic schedules||End of quarter||Shred|
|Daily script journal||6 years||Shred|
|Insurance billing records||6 years||Shred|
|Patient billing records||6 years||Shred|
|Patient charts||30 years||Shred|
|Patient payment records||6 years||Shred|
|Prescription records||6 years||Shred|
|Treatment contracts||6 years||Shred|
|Job applications||1 year||Shred|
|Employee Benefit Plans||1 year||Shred|
|Leave forms||3 years||Shred|
|Employee identification (I-9)||4 years||Shred|
|FICA payments||4 years||Shred|
These retention schedules are intended only as a guide. Before destroying any records, it is advisable to confer with your attorney, CPA, or other legal advisor.
Create a Dental Records Destruction Policy
The Department of Health and Human Services requires that â€œâ€¦covered entities must implement reasonable safeguards to limit incidental, and avoid prohibited, uses and disclosures of PHI, including in connection with the disposal of such information. In addition, the HIPAA Security Rule requires that covered entities implement policies and procedures to address the final disposition of electronic PHI and/or the hardware or electronic media on which it is stored, as well as to implement procedures for removal of electronic PHI from electronic media before the media are made available for re-use.â€
In order to comply, records retention plans should include a clear policy for records disposal. Key terms include:
- Proper handling of old prescription bottles in transparent bags and locked until retrieved by disposal company.
- Proper destruction methods. Even seemingly unreadable documents must not be trashed or recycled, but rather shredded by a vendor trained and certified in HIPPA regulations regarding document destruction. This will ensure security of personal information will be properly destroyed, but will also remain secure in transit if necessary.
- Destruction and purging of any hard drives containing personal health information.
All documents or hard drives that are awaiting destruction should be stored in secure, lockable, paper collection containers. Electronic records and hard drives must be destroyed as well in a timely manner and in accordance with HIPAA regulations.
Partnering with a fully, HIPAA-compliant, NAID certified shredding company is the best way to assure your documents are destroyed properly.
Choose a Professional Shredding Service
A trusted document disposal method is the equally-important counterpart to a document retention method. When the proper policies and regulations are understood, a company can make an informed decision on which professional shredding service they should partner with. A shredding company will specify if their services are compliant with the regulations specific to your industry.
The mobile and on-site shredding services offered by Shred One provide routine shredding based on any schedule of document management. The benefit of this shredding service is that the specific shredding schedule that a company policy dictates can be met routinely and efficiently.
Take these steps at your practice and keep you staff informed and empowered to implement the retention and destruction plans to ensure patient information security, reduce risk, and improve office organization.