Q&A: Our facility primarily uses electronic health records. Are there any items that require the original hard copy to be retained or can all items be shredded once scanned?

By Judi Kulus, RAC-MT,DNS-CT,MAT,RN,NHA - January 24, 2018

Question: Our facility primarily uses electronic health records. Are there any items that require the original hard copy to be retained or can all items be shredded once scanned? Also, is an electronic signature in electronic records sufficient or should the signature page be printed out for an actual hand-written signature?


Answer: You ask a very great question. I did a little research and here are some great information pieces to assist you. This article, while from 2013, is well-written and outlines the concerns with shredding EHR documents. Find it here: Retention of Paper Medical Records After Converting to Electronic Health Records.
Just as I suspected there is no easy answer or the answer depends on which document you are considering shredding. The article above summarizes the issue by saying:

Summary:  There is no single answer for how long to keep the original paper medical records. The CMS view seems to be that once records are converted to electronic storage media, and the converted image is identical to the original, the paper versions need not actually be retained at all. However, if you have notice of possible litigation or a fraud enforcement action, then it would be prudent to retain the paper versions. Even in the absence of litigation or an impending federal enforcement action, you may decide to retain the paper records for the minimum of the applicable limitation period for a malpractice action, the five-year period indicated by Medicare, or as long as the ten-year False Claims Act statute of limitations. At a minimum, have a written retention policy that contains quality control procedures and that ensures paper records are not destroyed before their scheduled backup to an identical image.

Here is another great read: What to Know Before Converting Paper Medical Records to EMROne key item to note is that in the Medicare General Information, Eligibility and Entitlement Manual it also stipulates that EMRs can only be used (and paper files can only be disregarded) if the EMR matches the paper file perfectly. Using your legal council and QA, set up a policy and procedure on how you will handle the paper documents.


Interested in reading more FAQs? Visit the AADNS Network where you can review questions and answers on pressing topics from peers and experts in long-term care nursing leadership.


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