Record-Keeping Beyond Charts

Here’s a question for you…

What comes to mind when you hear the word “record”? More than likely, you think about a medical record. Right?

Well, you’re not alone. When most providers think “record,” they think about a patient chart.

And even though medical records are central to any practice, other documents must also be managed.

Every aspect of your practice generates records that must be organized, protected, and retained for specific periods, including financial and employee records, vendor contracts, and OSHA documentation. Failing to do so can lead to compliance violations, legal issues, and operational headaches.

In this article, we’ll explore the types of records your practice generates and must keep, and how long you need to keep them. We’ll also touch on strategies for managing records efficiently and securely.

Types of Records Your Practice Must Keep

1. Clinical and Medical Records

No surprise here…

Every practice must keep all records related to patient care, including progress notes, treatment plans, lab results, imaging, and prescriptions.

HIPAA-related documents, such as privacy notices and release-of-information forms, also fall under this category.

2. Financial Records

Every business is required to track and record all income and expenses. So, every dollar that comes in and goes out of your practice must be documented, including:

• Billing records
• EOBs
• Accounts receivable
• Patient Invoices
• Bank records
• Purchase receipts
• Payroll records
• Tax records
• Expense receipts and documentation
• Etc.

3. Administrative and Business Records

This category includes your practice’s foundational paperwork:

• Business & professional licenses
• Continuing education documents
• Tax IDs
• Federal registrations
• Vendor and lease agreements
• Malpractice insurance records
• Credentialing records
• Collaborative agreements
• Etc.

4. HR and Employment Records

If you have employees, you have additional record-keeping requirements. Employment files must be retained for legal and HR compliance and include the following:

• Job applications
• Job descriptions & performance evaluations
• Disciplinary action
• Employment termination
• Employment contracts
• Timecards
• Etc.

5. Legal and Compliance Documentation

Don’t assume you’re exempt from record-keeping requirements because you have few or no employees.

Even small or solo practices must comply with many federal, state, and industry regulations.

While the documentation load may be lighter than that of a large group practice, certain legal and compliance records are still essential, and often required by law, including:

• Incident Reports: in case of patient injuries, privacy breaches, or adverse outcomes.
• OSHA and Workplace Safety Documents
  • OSHA regulations apply even if you have just one or no employees, if you’re handling certain hazardous materials or medical waste.
  • Required documents may include:
    • OSHA 300 logs (if applicable)
    • Sharps injury logs
    • Employee training logs on bloodborne pathogens, infection control, or other relevant safety topics

• Licensing and Credentialing Files:
  • Professional licenseDEA certificateBoard certificationsMalpractice insurance policies
  • Etc.
• Compliance Program Policies (even if you’re a solo provider)
  • A basic compliance program should include:
    • Written policies and procedures
    • A code of conduct
    • A defined process for reporting and handling potential compliance issues
  • CMS and OIG recommend this even for small practices, especially those billing Medicare or Medicaid.
• Audit Trails and Internal Reviews
  • Keep records of your self-audits, such as chart reviews for coding accuracy, or checks to ensure your practice follows HIPAA protocols.
  • Internal reviews help prove that you’re taking reasonable steps to stay compliant, even if you don’t have a formal compliance officer.
• HIPAA Documentation
  • Keep signed patient acknowledgments of your “Notice of Privacy Practices.”
  • Maintain records of Breach Notification Policies, Business Associate Agreements, and Access Logs (if applicable).

Record Retention: How Long is Long Enough?

While record retention periods vary depending on federal and state laws and the record type, below are some general guidelines.  

Note: always check with state law, the agency, or the payer contract requirements for the records-retention rules.

Keep…

• Medical records for ten years after the last visit (check state law).
• Business financial & tax records for 7 years (check current IRS rules).
• HR & Employment records up to 7 years after termination.
• OSHA & Safety records: typically, 5 years, possibly up to 30 years.
• Contracts & other legal documents, at least six years after resolution

Strategies for Managing Your Records

Managing all records effectively can be challenging. Here are a few suggestions to make it easier.

Use a Secure & Safe Storage System

• For physical records, ensure locked cabinets in secure rooms (if possible).
• For digital records, use encryption, password protection, and multi-factor authentication.
• Always back up data in a secure cloud or off-site location.

Create and Use a Records Policy

Develop a written retention and destruction policy, defining:

• What record to keep
• Who is responsible
• How long will records be kept
• How records are securely destroyed when no longer needed

Conduct Routine Audits

Perform periodic internal audits to help you stay ahead of potential compliance issues. Check for outdated files, incomplete records, or security vulnerabilities before an outside auditor does.

If you have employees, make sure they are adequately trained and understand what records to save, how to store them, and how to protect confidential information.

Regular training helps prevent costly mistakes!

Stay Compliant and Audit-Ready

Regulatory bodies can request access to your records at any time, especially if there’s a patient complaint, insurance dispute, or government audit.

Being audit-ready means having an organized system where documents are complete and easy to locate. Regular compliance reviews help you catch and correct any deficiencies before it’s too late.

In Summary…

Record-keeping in your practice is not just about organization; it’s also necessary to maintain compliance.

Properly managing your clinical, financial, administrative, and legal documents protects your patients, license, and business.

Set time aside to assess your current practices. If necessary, update your policies, and invest in systems that support secure, streamlined, and compliant record management.

You won’t regret it!

We’d love to hear from you…

Tell us what you think. What are your secrets to managing the records in your practice?

By Johanna Hofmann, MBA, MAc., EAMP; regular contributor to the NPBusiness blog and author of “Smart Business Planning for Clinicians.“