Federal Regulations for Clinical Records

Clinical or medical records are very valuable to patients and healthcare professionals alike. These records indicate personal information about the patient and contain detailed information of patient history, treatment and other confidential information. For this reason, federal regulation places specific standards on clinical records to prevent breaches of confidentiality or privacy.

Federal Law

• Two specific federal laws geared towards protecting patient privacy--for health care providers and consumers alike--are the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Patient Safety and Quality Improvement Act of 2005 (PSQIA). HIPAA focuses on the privacy and security rules of clinical records, while PSQIA focuses on patient safety rules.

Retention Schedules

• To maintain confidentiality and privacy, medical records must have a retention schedule, according to federal regulation. Medical records include more than hard copies and files; they may also contain diagnostic images, surgery recordings and registers of births and deaths. Federal regulations recommend that diagnostic images, such as X-ray films, should be retained for 5 years. Disease, physician and operative indexes--which explain diseases, physician specialties and duties and performance methods in caring for or treating such diseases--should be kept on file for 10 years.

  Adult patient health and medical records should be filed for 10 years after the most recent patient activity. It is recommended that minor health and medical records have a retention period to the age of majority plus the statute of limitations. Births, deaths and surgical procedures should be retained indefinitely.

Access

• Under federal regulations, patients have unlimited access to their clinical records and must provide a release authorization to allow other professionals or agencies to access such information. Healthcare professionals who provide care must also follow this procedure and not release medical records or information unless permitted.

Compliance

• Under the Health Insurance Portability and Accountability Act (HIPAA), all medical professionals must follow written policy and procedures to maintain confidentiality and privacy of clinical records. Following compliance regulations means that health care professionals attend training sessions, seminars and evaluations to ensure that compliance measures are being followed properly.