Privacy >> TUSDM Policy on Retention, Storage, and Disposal/Destruction of Medical Information

TUSDM Policy on Retention, Storage, and Disposal/Destruction of Medical Information

I. Purpose and Scope: 
  1. The Tufts University School of Dental Medicine (TUSDM) is committed to maintaining the health information of its patients as it applies to the designated record set whether the information is paper-based, electronic, or other medium. This policy applies to any health information maintained in the Records Management Department or by the clinical or ancillary department that documented the information, including any physical hardware and software.
II. Policy Statement: 
  1. TUSDM is committed to maintaining and retaining health information and records. The organization will follow retention schedules and destruction procedures in compliance with applicable legal and regulatory requirements.
  2. This policy outlines the retention period and storage guidelines for medical records within TUSDM; sets conditions and time periods for which medical records will be stored, retained, and/or destroyed after they are no longer needed for patient care or business purposes; and to ensure appropriate availability of medical records. TUSDM's Retention, Storage, and Disposal/Destruction of Medical Records will meet both requirements set forth by the Massachusetts Board of Registration in Dentistry advisory opinions, the Code of Massachusetts Regulations, Massachusetts General Laws, and the contractual requirements of Centers for Medicare & Medicaid Services and private payers for retention, storage, and disposal/destruction of medical information.
IV. General Rules: 
  1. Retention of Records:
    1. TUSDM follows the record retention and destruction of medical records regulations as outlined by the Department of Public Health within the Commonwealth of Massachusetts Executive Office of Health and Human Services. Medical records must be retained for the entire retention period as outlined in the Circular Letter (DHCQ 09-07-515, dated July 22, 2009. However, TUSDM reserves the right to maintain records longer than required.
    2. For Occupational Health and Employee Health records TUSDM will adhere to Federal Record Retention Guidelines.
    3. During the retention period, records will be protected from alteration, tampering, loss, and physical damage.
    4. For records maintained by Health Information Management and other clinical areas, retention will follow guidelines. Each department will review and assess record needs based on space constraints and will determine if they are suitable for archiving in reference to department policy.
  2. Storage of Records:
    1. Storage areas for inactive records can include either an area inside the facility that has been approved for records storage use, or an off-site, private, professional record-storage facility with which TUSDM has an active contract for storage and retrieval services. NOTE: Storage warehouses, mini-storage facilities, and off-campus personal or rental property, including garages, basements, homes, trailers etc., are UNACCEPTABLE for storing inactive medical records.
    2. Approved storage areas must be physically secure and environmentally controlled to protect records from unauthorized access and damage or loss due to temperature fluctuations, fire, water damage, pests, and other hazards.
    3. Any inactive records moved to off-site storage must be boxed, labeled, and logged out of our medical tracking system so they can be efficiently accessed and retrieved if necessary.
    4. Any paper-based records involved in litigation or investigation are considered active records and will be stored on-site in a secured file designated as such.
  3. Destruction of Records:
    1. In the absence of investigation, litigation, or legal hold, records that have met their legal, fiscal, administrative, and archival requirements may be destroyed in accordance with retention as outlined by the Department of Public Health in circular letter DHCQ 09-07-515 (Attachment A: Record Retention Guidelines) or as deemed appropriate beyond the maximum retention period by TUSDM.
    2. No entire medical record shall be destroyed on an individual basis.
    3. Records should not be destroyed if they are currently involved in open litigation, lawsuit, or subject to any government investigation or similar activities. Once the litigation, lawsuit, or government investigation has been completed, records may be destroyed accordingly.
    4. Paper records that are scanned into any electronic medical record system that has been approved by the TUSDM Medical Records Supervisor of the TUSDM Medical Records Department, will be destroyed after scanning, indexing, and 100% quality checking has occurred. Keep scanned records in an electronic storage system approved by TUSDM Medical Records Supervisor. Destroy the original paper records on-site immediately after scanning, indexing and quality checking. Authorization for destruction in these circumstances will be in accordance with rules set by the Department of Public Health using the Records Destruction FAX Notification Form (Attachment B: Record Destruction Form for approval.
    5. Unscanned paper records may be destroyed after completing the (“the Records Disposal Authorization” form [RC-108.1]) by TUSDM (Records Management Liaison Officer [RMLO]). Final approval by the (Public Records Administrator and the State Archivist) must be obtained before any records can be destroyed.
    6. Destroy all medical records so that the information they contain cannot be retrieved, recognized, reconstructed, or practically read.
    7. Destroy all medical records in reference to Disposal of Documents/Materials Containing PHI and Receipt, Tracking and disposal of Equipment and Electronic Media contain Electronic Protected Health Information.
V. Policy Compliance Monitoring and Enforcement: 
  1. The Associate Dean for Clinical Affairs will annually update the Compliance Committee and will report annually to the Patient Care and Quality Assurance on the number of and reasons for retained, stored, disposed/destroyed medical records.
VI. Potential Disciplinary Actions and Sanctions: 
  1. Members of the TUSDM Community who do not comply with this policy may be required to participate in additional training or be referred to the appropriate Ethics, Professionalism, and Citizenship Committee or Department Chairs for potential disciplinary action. 
VII. Related Policies, Procedures, Forms: 
Notice of Privacy Practices
Statement of Patient Rights & Responsibilities
VIII. Approval and Review Cycle: 
  1. This policy will be subject to annual review, revision, and approval by the TUSDM Patient Care and Quality Assurance Committee and, in the event of material changes, official adoption by the TUSDM Executive Faculty. 
Attachments: 

Attachment A: Record Retention Guidelines

Attachment B: Record Destruction Form