Dentists should establish record retention and disposal protocols, set them into policy and review them annually.

Posted in Risk Management on Tuesday, April 12, 2016

“How long should I keep dental records?” This is a common question I hear from dental professionals. Unfortunately, there is no easy “one size fits all” answer to this question. The answer depends on the circumstances that surround a patient and a practice location. Additionally, one must consider the fact that record retention is only part of the issue and that a proper disposal protocol is also necessary. For these reasons, dentists should establish dental record retention and disposal protocols, set them into policy and review annually.

One key element to developing a record retention and destruction policy is to clearly state the required length of time to keep records. Do not forget that different situations, such as that of a minor, a competent adult, an incompetent patient, a deceased patient, etc., often have varying retention lengths.

Prior to implementing a retention and destruction policy at your dental practice, it is important to ensure you are thoroughly educated on the questions and facts below: 

• If the patient is or was a minor, records should be retained until the patient reaches the age of majority - and then for a specified time period after that date.  
  • Remember, the age of majority differs between states.  
• If the patient is or was incompetent at the time of treatment, what are the rules?  
  • Some states require these records be retained until after the death of the patient. 
• If the patient is now deceased, how long should records be retained?  
• If the patient was covered by Medicare or Medicaid how long must records be kept?  
  • The general rule is at least five years; however, this should be confirmed due to continual changes.
• If there is a dispute involving services, does this affect the retention period?  
  • Generally, records should be kept until the dispute is resolved and then the specific length of time based on your state code.

State laws statutory codes, may dictate the required timelines in your state. The best resource for necessary retention lengths specific to your state statutory code and statute of limitations is your local dental association or legal counsel.

Your record retention and destruction policy should also clearly identify how to destroy records. Before destroying any records (shredding or incinerating – caution: x-rays should not be burned), it is important to understand your responsibility in maintaining the confidentiality of a patient’s protected health information (PHI). Protocols should clearly define the steps before destruction, such as:

• Patient criteria based on statutory code and statute of limitations has been reviewed and met
• The patient has been given an opportunity to obtain the information, if feasible, or have it sent to another provider
• Patient records to be destroyed have been entered into a master log (which is maintained indefinitely) listing the destroyed records and includes such information as:
  • The patient’s name
  • Date of birth
  • Last date of service
  • Date of destruction
  • Name of company or individual performing destruction
    • If a company is hired to destroy records, they should sign a confidentiality agreement and provide certification of the destruction
  • Method of destruction
  • Signature of individual witnessing destruction

For more information on this topic, visit DentistryIQ for the article “Developing an Effective Records Retention Policy for Your Practice.”