Health Record Retention Policy Development
What considerations will you consider in preparation for drafting your policy?
Identify 3 factors that could pose a disaster threat to health information along with suggestions for disaster recovery.
Explain how you will be guided by the AHIMA Code of Ethics by specifically identifying the relevant ethics principle(s) and interpreting it in your own words.
As a new HIM director of a large healthcare system composed of multiple sub-acute care facilities with locations in multiple states of the US. You could use the example of Atlantic Health System or other similar health care organization of your choice (the selected organization must extend health care operations in more than one state). The organization uses an EHR but has some paper records, as well. One of your tasks is to put together a health record retention policy for the entire organization. Health Record Retention Policy Development
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What considerations will you consider in preparation for drafting your policy?,
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Identify 3 factors that could pose a disaster threat to health information along with suggestions for disaster recovery,
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Explain how you will be guided by the AHIMA Code of Ethics by specifically identifying the relevant ethics principle(s) and interpreting it in your own words,
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As a new HIM director of a large healthcare system composed of multiple sub-acute care facilities with locations in multiple states of the US, how will you address the need for a unified health record retention policy?,
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How will the organization’s use of both EHRs and paper records be incorporated into your retention policy?
Comprehensive General Answer
Considerations for Drafting the Policy
When preparing to draft a health record retention policy for a large, multi-state healthcare system such as Atlantic Health System, it is essential to consider:
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Federal and state regulations – Retention timelines vary by state and by record type. For example, Medicare requires providers to retain records for five years, while some states may require longer periods for pediatric or mental health records. A harmonized policy must meet the most stringent requirements across all states where the organization operates.
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Clinical and operational needs – Providers and administrators rely on access to health records for continuity of care, quality improvement, audits, and legal defense. Policies must ensure accessibility without burdening storage systems unnecessarily.
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Technology infrastructure – Since the organization uses both electronic health records (EHRs) and paper records, the policy must define processes for hybrid systems, including digitization of paper records and secure destruction after scanning, when appropriate.
Disaster Threats and Recovery Strategies
Three key disaster threats to health information include:
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Cyberattacks (e.g., ransomware): A major risk to EHR systems. Recovery involves implementing strong firewalls, encryption, employee training to prevent phishing, and maintaining secure, off-site backups to restore operations quickly.
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Natural disasters (e.g., floods, hurricanes, wildfires): Facilities across multiple states are exposed to different environmental threats. Solutions include redundant cloud-based storage, geographically distributed data centers, and paper record storage in climate-controlled facilities.
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Human error (e.g., accidental deletion or misfiling): Even with advanced systems, mistakes happen. Strong role-based access controls, audit trails, version tracking, and frequent training help mitigate this risk.
A comprehensive disaster recovery plan (DRP) should be integrated into the retention policy. This includes outlining responsibilities, specifying backup frequency, and conducting periodic drills to test readiness.
AHIMA Code of Ethics Guidance
The AHIMA Code of Ethics provides essential direction for HIM professionals. Relevant principles for this policy include:
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Principle II: Put service and the health and welfare of persons before self-interest and conduct oneself in the practice of the profession so as to bring honor to oneself, peers, and to the health information management profession.
Interpretation: As HIM director, I must ensure the retention policy prioritizes patient care and protection of sensitive health information over organizational convenience or cost-saving measures. -
Principle III: Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard health information and other information of a confidential nature obtained in an official capacity.
Interpretation: This principle guides the integration of both paper and electronic records into secure retention and disposal processes, ensuring confidentiality at every stage. -
Principle V: Advance health information management knowledge and practice through continuing education, research, publications, and presentations.
Interpretation: By developing a comprehensive and compliant retention policy, I contribute to best practices that can be shared across the healthcare system and beyond.
In short, my decisions will always reflect ethical obligations to safeguard patient information, support quality care, and maintain trust in the healthcare system.