What Should You Do When Dental Records Are Damaged?

Although no one wants to envision the possibility, natural or man-made disasters and building malfunctions can befall a dentist’s office, resulting in the partial or complete destruction of dental records. Weather events and other catastrophes do not, by themselves, automatically absolve a dentist from the responsibility to maintain patient records. If an untoward event does occur, certain steps should and must be taken to satisfy legal obligations and mitigate the harmful effects of the loss.

So what should you do? Here are some helpful tips from our Fall 2016 Dental Dateline:

Know the record retention guidelines
According to New York law and regulations, dentists must maintain all patient records for at least six years. Records of minor patients must be retained for at least six years and until one year after the minor patient reaches the age of 21 years. These are statutory minimum standards. Because of the statutes of limitations which apply to malpractice and fraud claims, it is recommended that dentists maintain medical records for at least 10 years after the date payment was last received for the patient.

Report the loss
In the event of a flood, fire, or similar event, you should immediately notify any insurance carrier which covers your building, its contents, and your business operations. Take photos and make a complete inventory of the loss. In the event of a dental liability claim, documentation will be important to protect you against any allegation of intentional “spoliation” of evidence.

Salvage the information
Since dental records may not be replicated easily, attempt to salvage as much information as you can. There are companies which specialize in this. Be aware that you may need a HIPAA business associate agreement with any vendors who have access to protected health information.

Properly destroy what cannot be salvaged
If the records cannot be salvaged, then protected health information must be cleared, purged or destroyed so that nothing can be used to identify patients. It is advised that, prior to destruction, you have an independent expert verify that the records cannot be salvaged. Keep this verification with your documentation of the loss. The Department of Health and Human Services has published a set of frequently asked questions on disposal of protected health information.

Recreate what you can
Try to reconstruct the charts as best you can by contacting other sources, including the patient, practice management software, transcription or other outside services and dental insurance carriers. A reconstructed chart should be clearly labeled as such, with a notation as to the current date. If reconstruction is not possible, then you must create a log of patient records which were lost.

This post is a partial reprint of an article in the Fall 2016 Dental Dateline titled, “There was a Flood/Fire/The Dog Ate My Records… What Do I Do Now?” For more information about the suggestions presented here, along with additional information, please read that article in full. It starts on page 12.