The current policy addresses the retention and destruction of medical records in the normal course of business. However, you noticed that it does not include instructions for how employees should respond to a litigation hold. Ultimately, the policy will need to be updated, but in the meantime, you decide to create a short training document to educate the staff.
Instructions
In a two (2) page training document, written using proper spelling and grammar, as well as professional tone and vocabulary, address the items below.
Differentiate between the three (3) legal terms below by explaining each and comparing them to one another.
Litigation Hold
Notice of Preservation

Order for Preservation
Provide instructions explaining how the staff should handle a litigation hold.
Rasmussen Hospital: Medical Record Management
Policy #
Policy Title:
Effective Date:
Revision Date:
Forms #:
6.01
Document Retention
10/23/2003
05/01/2019
None
Policy
It is the policy of Rasmussen Hospital to apply appropriate and cost effective
management techniques to maintain complete and accurate records.
Records are retained in accordance with all applicable laws and regulations
and this policy. The purpose of this policy is to establish the policy and
procedures for the creation, use, maintenance, retention, preservation and
disposal of Rasmussen Hospital’s records in order to:
1) Meet current Company needs in record storage (or other electronic
media) and retrieval systems
2) Ensure compliance with the various governmental regulations concerning
document retention
3) Ensure uniformity in records retention throughout the Company
General
Information
1) Records shall not be destroyed before the prescribed retention period has
expired. Records shall not be retained for longer than the prescribed
period without first contacting the applicable department head.
2) Retention periods are specified for original documents only, unless
otherwise specified. Duplicates of original documents should generally be
properly destroyed after use, unless the retention of such duplicate
original document is necessary to support current operations. If duplicates
are retained, they should be properly destroyed after they have served
their purpose.
3) Records containing confidential and proprietary information will be
securely maintained, controlled and protected to prevent unauthorized
access.
4) All records generated and received by Rasmussen Hospital are the
property of Rasmussen Hospital. No Rasmussen Hospital employee, by
virtue of his or her position, has any personal or property right to such
records even though he or she may have developed or compiled them.
5) Any unauthorized destruction, removal or use of such records is strictly
prohibited.
6) No person shall falsify or inappropriately alter information in any record or
document. Information pertaining to unauthorized destruction, removal or
use of Rasmussen Hospital records or regarding falsifying or
inappropriately altering information in a record or document must be
reported to management.
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Rasmussen Hospital: Medical Record Management
Procedure
Policy 6.01 Document Retention
The following special considerations apply to the application of Rasmussen
Hospital Document Retention policy and procedure.
1) Records Relevant to more than one category When records may be
subject to more than one category and corresponding retention period,
employees must use the longest retention period.
2) Copies Only one copy of each record must be retained to comply with
record retention requirements.
3) Exceptions Any exceptions to Rasmussen Hospital’s Document
Retention policy and procedure may be made only after consultation with
the Compliance or Legal Department.
4) Assistance Employees should never guess as to the retention period
applicable to a particular record or category of records. Any questions in
this regard should be directed to the Supervisor/Manager who shall
consult with the Compliance or Legal Department as appropriate.
Last Reviewed: 05/01/2019
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Rasmussen Hospital: Medical Record Management
Policy 6.01 Document Retention
Rasmussen Hospital Document Retention Resource
Record Type
Medical Records of Patients
Retention Period
10 years from date of
discharge
Any items scanned and attached to
electronic medical record
Until verification is
completed by the patient
service specialist to
ensure all documents are
scanned, attached to the
electronic medical record
and legible.
10 years from the date
the minor turns 18 years
of age
Current Year + 2 years
Medical Records of Patients – Minors
Appointment / Schedule Book
Informed Consent General release
Forms; Program Agreements/Release
Waivers
Patient Sign-In Sheets
Fax Cover Sheets
Current +7 Years
Daily Close Reconciliation Packet
? Co-pay pack (Co-pay Checklist /
Daily Receivables log, TS Copay
Collections Report, InstaMed
Deposits Report, signed credit
card receipts, scanned money
orders)
? TS End of Day Reconciliation
Report
? TS Completed Notes Report
? Accepted Visits / Rejected Visits
Report
? RT Billing Coding Edit Report
? RT Billing Reconciliation Report
? Daily Charge Reconciliation
Report
? Batch Information Report
? RT Charges Posting
Reconciliation Report
Manual Charge Tickets
Most current 15 months
unless otherwise noted
below
Current Year + 2 years
Current Year + 1 year
Comments
Follow state regulations regarding
Medical Record retention when
stricter
Follow state regulations regarding
Medical Record retention when
stricter
Patient schedules that are
maintained or modified on paper
must be retained as noted in
“retention period”. Electronic
schedules (i.e., TherapySource) that
can be recalled from a computerized
system are not required to be
retained in a paper format.
From policies 5.25, 5.26 and 5.30
NA
Per HIPAA Policy H-21A procedure
5
CBOs will retain for co-pay pack for
10 years with the exception of
original credit card receipts.
Until verification is
completed by the patient
service specialistto
ensure all documents are
Page 3 of 5
Rasmussen Hospital: Medical Record Management
Policy 6.01 Document Retention
Rasmussen Hospital Document Retention Resource
Record Type
Organizational Charts
Management reports (Examples:
Income statements, KPI reports,
referral tracking reports)
Retention Period
scanned, attached to the
electronic medical record
and legible.
Until superseded by new
organizational chart
While useful in the center
Comments
NA
Any reports generated from the RMT
or Oracle system do not need to be
retained in hard copy.
Administrative Logs (staff schedules,
day-to-day management of office
personnel / functions, petty cash
requests)
Current + 3 years
NA
Invoices
Signed staff time cards
Clinical Quality Assurance Audits
Current + 1 year
Current + 7 years
For audits completed by
hand or Excel
spreadsheets, maintain
current year plus previous
year.
NA
NA
NA
Customer Complaint Forms
Net Promoter Surveys
Clinical Operations Policy and
Procedure Manual
Center Handbook Documents
?
?
Equipment Calibration
Safety Procedures pertaining to
security of patients and/or
employees
? Evacuation drill reports
? Safety Inspections of building or
equipment
? Meeting Minutes
Contracts – Medical Director,
Contract Employees and Lease
Agreements
Personnel Files of Employees and
other employee records (unless noted
below)
? Employee Medical Records
? Performance Appraisals /
Compensation Adjustments /
Awards and recognition
? Company sponsored education
Audits entered into the
SM QA database, NA
Current year + 6 years
Most recent 4 quarters
Current policies
Current + 1 year unless
otherwise noted below
Current year + 3 years.
NA
NA
NA
Keep the previous year’s records in
a separate folder to decrease size of
the Center Handbook.
Includes all records documenting the
inspection of facilities for potential
safety hazards
Term of Contract + 6
years
NA
Term of employment + 5
years
NA
Current + 7 years
Term of employment + 2
years
NA
NA
Term of employment + 2
years
NA
Page 4 of 5
Rasmussen Hospital: Medical Record Management
Policy 6.01 Document Retention
Select Medical Outpatient Division Document Retention Resource
Record Type
? Job related accidents and injuries
? Employee Exposure Incidences
or documents recording incident
Incident Reports
Record Destruction – records
supporting the documentation of
destruction of medical records
Retention Period
Current Year + 5 years
30 Years
Comments
NA
NA
Permanent
Permanent
NA
NA
Destruction of Records:
a) Medical records shall be shredded or after they have been retained the greater of the following:
i. Company policy as outlined in policy 6.01 (Document Retention),
ii. State law if more stringent, or
iii. Unique contractual requirements (if applicable)
b) Where required by law, notice of record destruction will be reported to the appropriate agency in accordance with
stated statutes, rules and regulations.
c) The Regional Director or Market Manager shall be responsible for ensuring there is a mechanism to destroy the old
records and that destruction is completed properly.
d) During the course of normal daily activities, parts of the patient’s medical record may be copied for business
purposes. These copies shall be destroyed by shredding once their purpose is completed.
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