greater washington society
for clinical social work

Promoting the highest standards of clinical social work practice through education, advocacy, and community.

Clinical Records Maintenance in the Tri-State Area

Tuesday, November 26, 2019 3:18 PM | Anonymous

November 26, 2019

DC: HORA [Health Occupations Revision Act] Title 3 Section 1210.11. page 138 -- specifies three years (but HIPAA requires six);

MD: https://health.maryland.gov/bswe/Documents/Regs/General/4-403.pdf

§ 4-403. Destruction of Medical Records

(e) After the death, retirement, surrender of the license, or discontinuance of the practice or business of a health care provider, the health care provider, the administrator

health.maryland.gov

https://health.maryland.gov/mbpme/Pages/records.aspx#retain

Medical Records

HIPAA regulations require that patient documents must be kept a minimum of six (6) years. The Medical Records Act states that unless a patient is a minor, medical records, laboratory and X-ray reports must be kept at least five years (see §4-403 below).

health.maryland.gov

Virginia: 

Maintain client records for a minimum of six years or as otherwise required by law from the date of termination of the therapeutic relationship with the following exceptions:

a. At minimum, records of a minor child shall be maintained for six years after attaining the age of majority or 10 years following termination, whichever comes later.

b. Records that are required by contractual obligation or federal law to be maintained for a longer period of time.

c. Records that have been transferred to another mental health professional or have been given to the client or his legally authorized representative.

https://law.lis.virginia.gov/admincode/title18/agency140/chapter20/section150/

Also of possible interest are the NASW recommendations, and another organizations policies, for comparison purposes. 

NASW:

https://www.naswassurance.org/pdf/PP_Record_Retention.pdf

Client Records: Keep or Toss? - NASW Assurance Services

Client Records: Keep or Toss? One of the thornier issues of social work today involves the why, when, and where of keeping clinical records. While hospitals and social service

www.naswassurance.org

Amer Academy of Pediatrics guidelines:

https://www.aap.org/en-us/professional-resources/practice-transformation/managing-practice/Pages/Destruction-of-Protected-Health-Information.aspx

Some practitioners keep records longer than legally required, for all sorts of reasons. The basic idea is to know what the statutes and HIPAA specify; and then beyond those requirements, use your own good judgment about when it's ok to shred your records.

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