Policy
Factors influencing retention periods include legal issues and compliance with federal and state laws. Further, bodies associated with health care, such as The American Health Information Management Association (AHIMA), provide recommendations for retention standards. Record retention entails ensuring patient health information is available for care and specifying what data is kept and for which duration.
Therefore, record retention involves the period during which a patient’s information is created and ends when the information is destroyed. Destruction of patient health information is conducted in line with the law pursuant to a policy approved by an appropriate organization (Underdahl et al., 2018). Any data under scrutiny or involved in the litigation process cannot be destroyed until such a process is concluded. Healthcare organizations should incorporate a method of destruction based on current technology and ensure patient data cannot be retrieved. E-discovery is a process where parties involved in a legal case collect, preserve, and review information for evidence. This process integrates information stored in electronic form for easy accessibility and disclosure.
Document Retention
Information concerning a minor or mentally incompetent individual cannot be released without authorization. However, information may be released to prevent abuse if a family member or guardian requests it in writing. Further, if clinicians observe that a mentally incompetent person is in danger of violence, they can release information. Thus, information about a minor or individuals who are mentally incompetent is safeguarded, and acquiring such data requires compliance with the law.
Procedure
A health record is documentation of a patient provided in the hospital and can be released at request (Underdahl et al., 2018). These records include; billing and medical records about an individual, payments made and claims, management records of a patient, and information used during the treatment process (Underdahl et al., 2018). All documents should be retained at the same time for the recovery process. Copies of these documents should have a signature to identify the responsible party. Healthcare should maximize technological advancement to ensure that all documents are stored electronically. Paper records may provide a different opinion from electronic records since they can be easily altered.
Reference
Underdahl, L., Jones-Meineke, T., & Duthely, L. M. (2018). Reframing physician engagement: An analysis of physician resilience, grit, and retention. International Journal of Healthcare Management, 11(3), 243-250.