Knowledge Base Article

CMS recently published MLN Matters educational article, SE1022, regarding medical records retention timeframes.  The article reminds providers that they should maintain an accurately written, promptly completed, accessible, properly filed and retained medical records for each Medicare beneficiary that is their patient.  CMS also encourages providers to use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.  The Medicare program does not have requirements for the media formats for medical records.  Medical records need to be in their original form or in a legally reproduced form so they may be reviewed and audited by authorized entities.  This form may be electronic as long as the provider has a medical record system that ensures the record may be accessed and retrieved promptly.  The article also reminds providers they may be eligible for incentive payments if they meaningfully use certified electronic health records (EHRs).
The record retention guidelines from the article and State requirements are as follows:

 For more information, see the   MLN Matters Article SE1022 and the Alabama Health Care Authorities Records Disposition Authority document.

Hospitals may wish to obtain legal advice concerning record retention after these time periods and medical document format.