PSYCHOTHERAPY RECORD KEEPING REQUIREMENTS

Judy Gallant, LCSW-C, Director, GWSCSW Legislation & Advocacy Branch

Bottom line: We must keep our records for the amount of time our state/jurisdiction requires. Additionally, for HIPAA, you must maintain – until 6 years after the last date of service - your privacy policies and procedures, privacy practices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented. And, for Medicare, records need to be saved for 7 years.

More specifically:

In MD and VA, this means we need to retain them for a minimum of 5 years after our discharge date. For minors, we must keep them either 5 years after their discharge date, or 3 years after they reach the age of majority, whichever is later.

In DC,  records need to be retained for 3 years after last seeing the patient. For minors we must keep records 3 years after last seeing the patient or for 3 years after the patient turns 18, whichever is later.

FOR HIPAA:

Does the HIPAA Privacy Rule require covered entities to keep patients’ medical records for any period of time? No, the HIPAA Privacy Rule does not include medical record retention requirements. Rather, State laws generally govern how long medical records are to be retained. However, the HIPAA Privacy Rule does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal. See 45 CFR 164.530(c). (From a CURRENT HHS.GOV posting: https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/enforcement/examples/disposalfaqs.pdf)

For Full Rule, go to p.3, bottom right: https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/enforcement/examples/disposalfaqs.pdf

And, for Medicare records:

For "a Medicare provider or supplier providing covered ordered, certified, referred, or prescribed Medicare Part A or B services….(t)he regulation requires you to maintain medical records for 7 years from the Date of Service (DOS).

From CURRENT CMS webpage: https://www.cms.gov/files/document/mln4840534-medical-record-maintenance-and-access-requirements.pdf

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