What Are the JCAHO Standards for Record Content Maintenance & Retention?

The Joint Commission -- formerly known as the Joint Commission on Accreditation of Hospitals Organization -- is a private, non-profit organization dedicated to setting higher standards for health care. Medical facilities of all types strive to achieve and maintain Joint Commission accreditation to demonstrate to their patients, communities and the health care industry that their facilities deliver quality medical care. The Joint Commission evaluates many aspects of a facility's operations, including how care is delivered and how information about care is recorded.

Complete Records

• In a 2010 communication, the Joint Commission reported that their rule -- RC.01.01.01 on complete and accurate medical records -- is the most important of all record keeping standards. Although the Joint Commission doesn't spell out in detail every field and item that must be included in a patient chart and medical record, it emphasizes that hospitals must make full use of each record per their own design. Of course, certain elements such as patient name, identification number, age, diagnoses, clinican notes, clinician actions, signatures, countersignatures, dates, details of procedures performed and medications administrated are industry standard, as well as legally required by most states. The Joint Commission expects all of these things.

Clarity

• Medical records aren't useful if they aren't clear and understandable. The Joint Commission looks for readability and clarity of communication within medical records. Notes and writing must be legible on paper records. The Joint Commission expects laboratory reports in standardized, computer generated formats to be included with all relevant patient records. Most importantly, every record must clearly show clinician name, credential, date and time for every service performed. Records must create a system of communication and an audit trail.

Security

• The Joint Commission supports and enforces patient privacy standards set by the federal Health Insurance Portability and Accountability Act (HIPAA). In fact, Joint Commission takes those requirements further by holding medical facilities responsible for time storage of documents in locked files and containers. It also encourages keeping patient charts in binders that prevent casual observers from viewing patient information, and mandates keeping a log of staff who access patient records. The health care industry's move toward electronic medical records makes record keeping protocols easier for staff, as security and storage moves into managed, secure servers with protocols designed for HIPAA compliance.

Storage

• States have different standards and requirements for medical record storage. The Joint Commission requires that hospitals comply with state laws and Medicare guidelines on record storage. While it recommends medical records be kept for at least six months, many states require facilities to store them for years. Arizona, for example, requires secure storage of adult medical records for six years form a patient's last visit, or until the patient reaches age 21 for pediatric patients. Many medical facilities elect to safeguard themselves against lawsuits by storing medical records in off-site storage for seven years or more. The Joint Commission, however, only requires compliance with state law and HIPAA privacy regulations.