Paper health records, often called medical charts, are physical documents containing a patient’s protected health information, including diagnoses, treatment notes, and test results. While the healthcare industry increasingly relies on Electronic Health Records (EHRs), paper records remain a reality for legacy data, specialized clinics, or as a backup during system downtime. Maintaining these charts requires rigorous procedures to ensure they are organized, accessible, and securely managed. This management involves detailed physical organization, strict access controls, and adherence to legal mandates for retention and eventual destruction.
Physical Organization and Filing Systems
The efficient retrieval of paper health records depends entirely on the chosen filing system, which allows staff to locate a specific chart among thousands quickly. Most healthcare facilities use a numeric filing system, where each patient is assigned a unique, permanent medical record number. The most straightforward method is straight numeric filing, where charts are filed consecutively from the lowest number to the highest number, but this causes congestion in the most current filing areas.
A more sophisticated and widely adopted technique is terminal digit filing (TDF), which distributes files evenly across shelving units to prevent any single area from becoming overwhelmed. In TDF, a six-digit number is broken into three two-digit sections, and charts are filed based on the last two digits (primary section), then the middle two digits (secondary section), and finally the first two digits (tertiary section). This system makes it easier for multiple staff members to file and retrieve records simultaneously. Color-coding is frequently applied to the file folders or labels, often corresponding to the digits of the patient number, which serves as a visual cue to detect misfiled records instantly.
Within the physical chart, maintenance is facilitated by the use of distinct chart dividers or tabs that separate sections like physician orders, progress notes, and laboratory results. The physical storage itself is typically housed in a centralized medical records room, using open-shelf filing units rather than traditional cabinets, as open shelving provides faster access and greater storage density. These records rooms must be carefully managed to ensure the physical integrity of the documents, protecting them from environmental damage like fire or water.
Access Control and Confidentiality Protocols
Maintaining the confidentiality of paper records requires strict physical and administrative controls to manage access and track movement. Physical safeguards include storing records in locked rooms or secured cabinets, often implementing a “double lock rule” where a locked cabinet is kept within a locked room. This layered security ensures that only authorized personnel can enter the storage area and access Protected Health Information (PHI).
Administrative protocols govern staff behavior and record movement outside of the central storage area. When a paper chart is removed, its location must be tracked to prevent loss and ensure accountability. This is commonly managed using an “out-guide,” a physical placeholder inserted into the shelf space where the file was removed, containing the name of the person or department that currently has the record and the date it was borrowed.
Staff training minimizes user error and prevents incidental disclosures, such as leaving a chart open on a desk in a publicly accessible area. Policies dictate that paper records must be closed or covered when not actively being reviewed, especially in patient care areas, to protect patient privacy from unauthorized viewing. Access to the records is granted only on a need-to-know basis, even for authorized employees.
Legal Mandates for Retention and Destruction
The maintenance of paper health records extends far beyond active patient care, as legal mandates require them to be retained for specific periods before being securely destroyed. The minimum retention period for adult records is generally six years under federal law, but state laws often impose stricter requirements, commonly mandating seven to ten years after the last date of service. Healthcare facilities must adhere to the longer of the applicable federal or state retention requirements.
Records for minor patients introduce a much longer retention challenge, as they must typically be kept until the patient reaches the age of majority, often 18, plus the state’s statute of limitations, which can result in storage requirements of 20 years or more. Before final destruction, some facilities may choose to convert older paper charts to a more manageable medium, such as microfilming or scanning them into an electronic format, to reduce the physical storage burden.
Once the mandatory retention period has expired and no legal hold is in place, the records must be destroyed in a manner that ensures the information cannot be reconstructed. Acceptable methods include secure industrial shredding, pulping, or incineration. This destruction process must be formally documented in a permanent log, detailing the records destroyed, the method used, the date, and the signatures of the individuals who supervised and witnessed the destruction.