Everything You Need to Know About Compliant Recordkeeping

Dental practices should take extra precaution to keep patient and medical records secure.

How compliant is your record storage system?

Chances are, if you’re a small, independent practitioner, you don’t have the luxury of a human resources department that can answer important questions — questions like, can you keep certain types of files together? Or, how long do you have to hold job applications for someone you didn’t hire?

The answers are imperative, and they are just the tip of the iceberg. Dental offices, explains Jaime Lizotte, HR solutions manager for ComplyRight, are not atypical of any small business.

“They’re regulated by the same authorities other businesses are,” Lizotte says.

Those authorities include the Department of Labor, which houses various divisions such as the Wage and Hour Division, OSHA and the U.S. Customs Immigration Service — each with its own menu of risks and penalties that could significantly impact a dental practice.

FINANCIAL IMPLICATIONS

Lizotte explains that the fines and penalties imposed by various government agencies can be as severe as imprisonment, depending on the violation. Employees at a dental practice could also pursue private lawsuits under various state employment laws.

“That’s where things get really complicated,” she says. “Employers need to understand these laws and regulations to make sure they remain in compliance and avoid getting into any hot water.”

One of the most common examples of lawsuits that Lizotte sees is with the Fair Labor Standards Act — the regulation for non-payment — which falls under the Department of Labor and the Wage and Hour Division. That could include lawsuits over unpaid wages for employees who didn’t get paid overtime but should have been paid because of their job duties and positions.

Lizotte also sees a lot of discrimination and harassment cases that come under Title 7 of the Civil Rights Act. Those cases could fall under the auspices of the Equal Employment Opportunity Commission, or possibly state discrimination laws.

When it comes to defending these types of lawsuits, the impact can be widespread.

“It can cost employers upwards of six figures,” Lizotte says. “And it’s not just the amount of money it costs. It also has an effect on employees within the practice in terms of their morale and retention.”

BEST PRACTICES

If a practice is still maintaining paper files, there are some important recordkeeping guidelines to be followed. For example, employee personnel files must be kept separate from patient records. And among employee records, medical information — such as any doctors’ notes or Workers’ Compensation documentation — must be kept apart from any basic employee information.

“Businesses should actually take extra measures to make sure medical information is locked and secured so that other employees can’t access these records,” Lizotte says. “There should be a separate medical folder for each employee versus just putting all the medical information in one folder.”

It’s also a good idea to keep all employee I-9 records separate. These are the forms used for verifying the identity and employment authorization of individuals hired at the practice. It’s not a regulation to do so, but Lizotte suggests keeping the I-9 records together and separate from all other employment records.

“This is so they can organize the file so that it’s tabbed with employee information,” she explains. “If they have any investigations, they’ll be able to easily access that information and only provide what they need for the investigator.”

TO ERR IS HUMAN

It’s inevitable that at some point an error will be made on a handwritten record. When that happens, Lizotte cautions never to white out any information.

“That would obviously appear to anyone who is doing an investigation that you’re trying to hide something,” she says.

Instead, cross out the inaccurate information and make a note next to it. Or, attach a separate sheet to the record indicating why changes were made to the form, what the changes were and the date they were made.

When it comes to I-9 forms, there are specific instructions for how changes are to be indicated. That includes making a line through the erroneous entry and attaching either a self-audit correction sheet showing the changes made with the date, or a brand new form reflecting the changes made.

IN THE CLOUD

If you’re migrating from a paper records system to an online, cloud-based system, or already using the latter, these online solutions often provide much of the compliance information that will alleviate the burden employers face to make sure they’re being compliant.

“And the best thing is that you’re protected from any natural disasters,” Lizotte says. “If a tornado hits and there’s nothing left of the practice, the records will still be available in the cloud, and can be accessed from anywhere.”