by Robin Desrocher and Tanya Babitch
In Texas, we have it all. And when a natural disaster strikes, it can be disastrous for your medical records. If your practice experiences such a loss, here are some guidelines for handling destroyed records.
Report the loss to your general liability/property insurance carrier. Keep the documentation sent to and from your property insurance carrier verifying flood or other event. In the event of a medical liability claim, this documentation could be important. Having the appropriate documents could protect you against an allegation of intentional “spoliation” of records
If any records are salvageable, make efforts to preserve them. There are companies that specialize in document remediation. Be sure to obtain a HIPAA Business Associate Agreement with any vendor (document restoration or destruction companies).
If the records are not salvageable and what’s left of them needs to be destroyed, be sure that your destruction (shredding, etc.) is complete and well documented. Keep a list of all patients whose charts were destroyed, along with details of what happened, dates, etc.
Try to re-create the charts as best you can by requesting outside records such as lab reports, diagnostic testing, operative reports, and other records. It may also be worthwhile to upload information from practice management software and investigate recovery of any recorded or transcribed records from outside services or voice recognition software. Any “re-created” records should be clearly labeled as such, with the current date. You may also wish to make a copy or photograph of the records.
The documentation should reflect what happened (flood, chart destroyed) and that the patient’s history is uncertain due to lost information as of (date), etc. At your discretion, you may consider whether to obtain new history forms and/or talk to the patient to gather additional history.
Health insurance carriers may require attestation forms regarding lost/destroyed records. Check with your carriers about this.
About the Author
Robin Desrocher is a Risk Management Manager at TMLT. Robin has more than 28 years of experience in the health care industry, including clinical operations in hospital and outpatient settings, health care administration, and coordinating continuing medical education for physicians and other health care providers. She joined TMLT in 2006. Robin Resrocher can be reached at email@example.com.More Content by Robin Desrocher