Record Retention Recommendations for Dental Practices
Record Retention Policies Are Critical for Your Dental Practice
It should be no surprise that your dental office needs to have formalized record retention policies and procedures that address (at a minimum):
• Duration for maintaining specific records
• Location for storing records, on-site or off-site
A dental office produces many types of documents, such as medical/dental records, regulatory documentation (HIPAA, OSHA, DEA), real estate, legal, employment, and others. All of these should also be included in the record retention policy.
Specific advice on the duration for retaining each type of document falls outside the scope of this writing, as it can vary significantly based on various factors. However, we can examine specific examples that reveal the nuances and complexities of this topic and provide some insightful general guidance advice.
HIPAA, State Laws, and Record Retention
There is a subtle distinction between HIPAA medical/dental record retention requirements and HIPAA record retention. The HIPAA Privacy Rule does not explicitly stipulate medical/dental records retention rules. Each state has laws governing the retention of these documents, and HIPAA does not preempt them. Therefore, under HIPAA, a “Covered Entity” is bound by their state law regarding how long they must maintain medical/dental records. Here are but two examples illustrating the differences in various state laws, thus the need to research the rules in the state(s) where you practice:
- Texas requires a dental office to maintain dental records for a minimum of five years. If a patient was younger than 18 when last treated by their dentist, the dentist should keep the records until the patient reaches age 21 or five years from the date of last treatment, whichever is longer.
- Illinois mandates that all records be retained for ten years.
Since there are no delineated HIPAA retention requirements for medical/dental records, what is the requirement for “HIPAA Records”? Documents subject to the HIPAA record retention rule are, for example:
- Notice of Privacy Practices
- Business Associate Agreements
- Authorization for the Disclosure of PHI
Additionally, § CFR §164.316(b)(2)(i) Policies and procedures and documentation requirements states:
(2) Implementation specifications:
(i) Time limit (Required). Retain the documentation required by paragraph (b)(1) of this section for six years from the date of its creation or the date when it last was in effect, whichever is later.
State laws may vary greatly, so check with your state’s dental board, applicable agencies, and your counsel for specific record retention requirements in your jurisdiction. A suitable resource for specific state record retention laws can be found on the Health IT website.
General Record Retention Guidelines and Recommendations
Having covered the HIPAA nuances and retention periods, let’s turn to a broader discussion. We recommend that when establishing a retention policy, include a review of all executed managed care agreements for their specific record retention requirements that you may be contractually obligated to. There are many types of documents generated in the administration and operation of a dental practice, including (but not limited to):
- Financial
- Insurance
- Legal
- Employment
- Real estate
- Payroll
- OSHA
- Controlled substances
Given the variety of the records and complexity of the retention requirements, we recommend that you seek the advice of the appropriate professional regarding how long, in what form, and where to retain such records.
Here are some general recommendations for the following basic record retention guidelines for your medical/dental records:
- For adult patients – retain dental/medical records for a minimum of 10 years after the last service date.
- For minor patients – keep dental/medical records until minors reach the age of majority (usually age 18) plus the time period specified by your state’s statute of limitations, or a minimum of 10 years since the last date of service (whichever is longer.)
- Store the medical/dental record indefinitely if – a claim or lawsuit is actually filed, you receive notice that a claim might be filed in the future, or there was a significant or unexpected adverse outcome.
Notwithstanding seeking specific guidance from an appropriate professional, it is prudent to maintain the following records permanently (especially given the ability to digitize the same). Check with the proper professional for guidance with your situation, including:
- Accountant’s annual report
- Capital asset records
- Cash receipt journal
- Canceled checks for significant transactions (like taxes or property)
- Contracts and leases (active)
- Deeds, mortgages, and bills of sale
- Depreciation schedules
- Financial statements
- General ledgers
- Income tax returns
- Insurance records and claims
- Retirement plan records
- Training manuals
- Important correspondence
- Legal agreements
Final Thoughts on Record Retention
An insightful and well-informed record retention policy will ensure proper continuity of care for your patients, help protect against future professional liability claims, mitigate the impact of and provide protection against complaints from the licensing board and other administrative agencies, and safeguard against billing audits, IRS audits, a myriad of law enforcement and administrative agency inquiries, and other contractual/legal issues an office may find itself verifying or defending.
The information contained on the DentistCare Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.
