Records Retention Policy For Hospital Closures, Mergers, and Consolidations

Primary Objectives

1. Protect the confidentiality of Patient Records
2. Assure future access by patients, new health care providers and other legitimate users.

When a health care facility closes, the following six factors should be considered

1. State laws regarding record retention and statutes of limitation,
2. State licensing standards,
3. Medicare requirements,
4. Federal laws governing treatment for alcohol and drug abuse, if applicable,
5. Guidelines issued by professional organizations; and
6. The needs and wishes of patients.

If a private facility that sub-contracts with the state should close, the following procedures must be followed to ensure adequate protection of the medical records.

1. Another health care provider must be sought to accept the records and inherent responsibilities. If another provider will not commit to taking the records, then either the State Records Center or a commercial storage firm approved by the Office of the Public Records Administrator should archive the records.
2. Patients should be offered the opportunity to obtain a copy of their records before the records are transferred to another facility, to the State Records Center, or to a commercial storage facility.

If there is a hospital merger or acquisition, the following procedures must be followed

1. Department managers must be involved in the planning process; and
2. Health information managers need to become involved once operational issues are clarified. Health information managers must examine the requirements for managing patient records, determine the standards to be met, and the available resources. Once this is completed, the system can be designed.

Three scenarios are possible

1. An operation at a single location.
2. An operation at two or more locations with separate licenses.
3. An operation at two or more locations with a single license.

There must be a written agreement between the facilities that will be merging that explains the disposition of patient records. This must include

1. A list of employees from each facility who are authorized to obtain records from the different facilities. The records cannot be disclosed without proper identification. The records must not be disclosed if the disclosure would violate any state or federal laws or regulations.
2. A provision designating which facility will retain possession of transferred records and will be responsible for their maintenance, protection, storage, and confidentiality until the "retirement" to the State Records Center in Rocky Hill or approved commercial facility.
3. A provision designating which facility will inherit the record retention responsibility and will retain the master patient index.

Documentation regarding responsibility for records must be filed with the Office of the Public Records Administrator at the Connecticut State Library.