Pathology Reports and Office Notes Document Management and Guidelines

Properly securing and storing pathology reports and office notes have a wide range of complications. In many offices it’s simply not done correctly, while others go above and beyond to make sure they’re in compliance—which wastes precious time and resources. Review the general guidelines for retention and then discover what you can do to streamline your own process.

Requirements for Storing Pathology Reports and Notes

Not all pathologists are bound by HIPAA requirements. Those that aren’t probably don’t have any federal requirements for their records, but there are likely statewide record retention laws that will vary by the type of record in question and the setting in which the record was obtained.

According to the Office of Civil Rights, HIPPA compliance doesn’t include medical record retention. However, HIPAA rules do require pathologists to apply the necessary technical, administrative, and physical safeguards to protect the privacy of patient information for the length of time those records are kept. The Centers for Medicare and Medicaid Services do require that records be kept for their beneficiaries for up to 5 years. The best advice is for offices to follow whichever applicable laws are the most stringent.

Determining Which Documents Should Be Kept

It’s not always simple to understand how long documents must be kept, which is further complicated by the fact that there isn’t a unanimous consensus on exactly which documents should be kept. The American College of Radiology has developed some of the most comprehensive suggestions involving record retention and they suggest pathologists and others in the medical community assume that “medical records” includes all radiographs and images that are produced via an examination. This also includes reports, films, scans, printouts, and any other images.

The Impossibility of Retaining All Documents

Many may wonder: Why don’t pathologists keep all pathology documents and reports? After all, with such nonspecific rules in place, it seems that the best and easiest way to ensure they have defensible medical records is to hold on to everything indefinitely.

The reality is that storing that many physical files has a wide range of issues that make it impractical, including:

  • Confidentially is critical. The more physical files an office has, the harder it is to ensure that all necessary security protocol are being followed.
  • Most offices simply don’t have room for this many documents.
  • A solution to the space problem is often having an offsite storage center, which not only eats up valuable money but requires a lot of duplication as pathologists work to ensure they have access to copies of the most relevant information onsite.
  • Generally speaking, the more physical files an office has, the more money they’ll spend sending files, copies, and notes back and forth from their office to patients.
  • Files can be lost. Whether it’s due to carelessness by employees, flooding, other natural disasters, or theft, if the only copy a company has is a physical copy then they’re putting it at risk by storing it offsite.

There is Another Side to the Document Retention Problem

Offices that have always used physical files can be resistant to change, but the reality is that there are a lot of good reasons to move to document management software (DMS).

Offices of all sizes can see a significant return on their investment right away:

  • Overhead costs are significantly reduced when there’s no longer a need for physical files. Not only can offices stop spending money on paper, copies, and postage, but they also gain a ton of human capital when they’re able to better utilize employees who used to spend hours every week filing and retrieving documents and files.
  • Better security is critical for pathologists in this day and age. Defensible medical records require either a paper audit trail or a digital one. Which one do you think stands up better in a court of law: One that’s recorded automatically or one that’s written in pencil and can be changed by anyone? But security doesn’t end there: DMS will have heavy encryption and will frequently backup data offsite, which means offices no longer need to have a disaster recovery plan that involves dealing with the fallout of hundreds or thousands of lost files.

The Many Benefits of eFileCabinet

When organization is key, nothing beats eFileCabinet. It provides solutions to all the issues listed above and many more.

Users can expect:

  • An organizational structure that’s easy to learn, customize, and use
  • 256-bit encryption that offers superior security
  • Role-based security allows lead users to decide who can access which documents
  • Built-in compliance with HIPPA
  • Third-party software integration so pathology offices can continue to use the programs they’ve trusted for years
  • An easier way to achieve optimal organization

If your office is ready to join the legions of satisfied customers who have walked into the future of document management, simply fill out the form on this page for a 15-minute video.

By | 2016-12-15T11:59:28+00:00 November 10th, 2015|
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