Dental records retention has never been straightforward. Competing state and federal laws, diverse patient details, and differences between digital and physical files make it a challenging part of practice management. These dental records retention best practices will help you stay organized and in compliance.
8 Best Practices for Dental Records Retention
Dental records retention is tricky because there are a lot of different and often contradictory laws around how long to hold them. While your state may set specific records retention periods, there are no unified standards. That is why your best practices should center on keeping that data organized and easy to manage.
- Set a single starting point. Your office should follow a uniform policy for when the clock starts ticking on inactive records.
- Audit your legal requirements. Review records for specific compliance and legal requirements.
- Categorize your records. Use the legal requirements to create retention policies for categories.
- Opt for longer periods. If there is a discrepancy between state retention and applicable laws, always opt for the longer period.
- Train your staff. All staff members should receive regular, at least annual, training on records retention requirements.
- Document your destruction safeguards. File destruction is not a single step; it's a process that requires secure management and compliance.
- Get legal signoff. Once you have a written policy, run it by a lawyer or compliance expert for approval.
- Build efficiency with technology. Practice management software and other programs can help you automate many retention tasks to stay compliant.
Setting a Starting Point for Dental Records Retention
In most cases, the dental records retention timeline starts from the patient's last appointment. The exception is for patients under eighteen, as their retention schedules will often be tied to when they reach the age of majority.
You also have to consider the types of records to keep. Patient medical charts and notes have different retention requirements than compliance-related records, like HIPAA training. Here is a basic breakdown of different record types, as well as recommended retention periods.
Personal information, medical history, treatment plans, and procedure notes.
Detailed records of dental treatments, procedures, and outcomes.
Radiographs and diagnostic images are used for treatment and assessment.
Invoices, payment receipts, insurance claims, and financial transaction records.
Communication records with patients, referrals, and other dental professionals.
Records documenting maintenance, calibration, and repairs of dental equipment and machinery within the practice.
Records related to incidents within the dental practice, such as accidents, injuries, or security breaches.
HIPAA compliance training, certificates, and documentation.
Auditing Dental Records for Legal Compliance
While most states will have an overarching records retention policy, it is usually shorter than other laws that might apply to patient records.
Consider the False Claims Act, which permits individuals to file lawsuits up to 10 years after someone submits a false payment claim to the US government. While your state law may specify a five-year record-keeping requirement, this changes when dealing with Medicaid recipients because that act is in play.
Any bills submitted could potentially be disputed for up to 10 years from their submission – as could any treatment related to those payments. The practice should hold records that could be affected for ten years following that patient's last visit to stay in compliance.
Review individual patient records for potential issues like this, as they could affect the retention schedule.
Some things to look for include.
- Patients under eighteen. The retention period usually doesn't start on a minor patient until they reach the age of majority – then it starts from the beginning.
- Government insurance. As noted before, government assistance patients may have longer retention periods due to laws like the False Claims Act.
- Legal actions. If a patient has been involved in a legal action related to your practice, these files should be flagged for indefinite retention.
- Specialist referrals. If you have referred a patient to a specialist, you may want to keep their records longer for continuity of care.
- Deceased patients. In the unfortunate event of a patient's death, maintain their records appropriately to address potential legal or estate-related matters.
Once you have reviewed your files for these potential red flags, you can create groups to set proper retention treatment.
Categorizing Dental Records for Clarity
Grouping physical patient files often involves color coding and tagging for easy organization and retrieval. This method also helps practices stick to retention schedules and legal requirements. By using colored folders to signify specific retention periods, staff can quickly assess when a file becomes eligible for disposal, or when one may need to be held longer.
In the digital world, Electronic Health Record (EHR) systems provide tools to organize records efficiently. They let practices create electronic folders, apply tags, and add metadata to records. This digital approach improves accessibility and allows for precise categorization based on patient details, treatments, or insurance status. It simplifies searching and ensures electronic records are well-managed and compliant with regulations.
Combining physical and digital grouping methods creates a comprehensive record-keeping system, making it easy to organize and access records, no matter what their format. This approach helps dental offices efficiently manage records, stay compliant, and provide top-notch patient care.
Opting for Longer Retention Periods
Often, patient files can be subject to multiple retention periods. For example, in Florida, the basic records retention requirement is four years, but someone on Medicaid might fall under the False Claims Act, mandating a ten-year retention period.
When uncertain, opt for the longer retention period. While it may take a bit more work, there are tools to streamline this. Practice management systems and ERS programs can expand your storage capacity by allowing you to transfer old physical files into electronic storage.
Training Your Staff to Stay in Compliance
Your records retention policy should be the sole source of truth for how your staff treats patient information. Your team should know their responsibilities regarding records access, use, and maintenance. Training should cover five categories.
Teach staff who can access patient records, when access is allowed, and how to request and obtain it.
Stress the importance of patient privacy and the ethical use of patient information.
Explain specific retention periods for various records and any exceptions based on legal requirements.
Train on secure methods for disposing of records after their retention periods, both physically and electronically.
Staff should understand and comply with healthcare laws like HIPAA and state regulations governing patient records.
Securely Destroy End-of-Life Information
The destruction step of every records retention schedule is usually glossed over, but it is a process in and of itself. You are responsible for securely destroying patient information when the schedule has expired. That includes the physical destruction of records and the digital deletion of data.
Physical File Destruction Steps
Digital File Destruction Steps
Get Legal Approval on Your Destruction Policy
One safeguard that practice managers should consider for all compliance-related tasks is legal representation. Practices should consult with a qualified attorney to help evaluate their data retention policy and make sure it complies with state and federal laws.
A good resource here might be your malpractice insurance. Your insurer has their own records retention policies that they require their policyholders to follow. Your policies should match or exceed these standards.
Use Technology to Schedule Retention Reminders
Manually setting reminders for seven years from a patient's last appointment is impractical for several reasons. It is difficult to definitively identify a patient's last appointment, especially when they may continue receiving care or have planned future visits. Attempting to track and schedule retention periods for each patient manually is a time-consuming process that would require regular checks and assumptions.
Even basic computer software can automate this process. With the right system, you can configure retention periods to start automatically after each patient's appointment. Any subsequent actions, such as scheduling follow-up appointments, can reset the retention countdown. This automation saves hours of manual work and ensures accuracy in tracking retention periods.
Of course, you should not depend entirely on technology for dental records retention. Human oversight is critical so you do not overlook any specific patient circumstances or exceptions that automated systems may not capture. While technology can streamline the process and reduce the risk of errors, foundational best practices should always be your fallback for records retention policies.