Understanding Hospice Clinical Record Requirements: A Guide to Proper Protection and Retention
In the hospice care setting, maintaining the security and integrity of patient records is not just best practice—it’s a regulatory requirement. Clinical records contain sensitive health information and are critical to ensuring continuity of care, supporting billing accuracy, and protecting patient privacy. The Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) have set specific standards under 45 CFR Parts 160 and 164, which hospices must follow to stay compliant.
Secure Handling of Clinical Records
Hospices are required to protect clinical records and the information they contain from loss, damage, or unauthorized access. This includes both physical and electronic files. Measures must be in place to prevent tampering, alteration, or unauthorized use by individuals who are not permitted to view patient information.
To meet these standards:
Use secure storage systems with restricted access controls.
Implement audit trails for electronic records.
Train all staff on HIPAA compliance and data privacy.
Routinely review access logs and document any disclosures.
Maintaining a strong data protection policy helps build trust with families and ensures your facility is in line with HIPAA and CMS expectations.
Retention Period for Clinical Records
Under federal regulation, hospice clinical records must be retained for a minimum of six years following the death or discharge of the patient. However, some state laws may require longer retention periods, so it’s important to cross-check with local regulations.
If your hospice stops operating or closes a location, you are still responsible for maintaining and safeguarding those records. You must:
Failing to retain records properly can lead to legal consequences, hinder claims processing, and compromise patient care history.
Implementing Best Practices for Record Security in Hospice Settings
Proper recordkeeping goes beyond regulatory checkboxes—it plays a central role in the daily operations of a compliant and high-functioning hospice. Whether you’re storing paper files or using electronic health record (EHR) systems, implementing a layered approach to security is key.
1. Physical Security Measures:
For paper records, ensure storage rooms are locked, access is limited to authorized personnel, and records are protected from environmental damage such as fire or water. Use lockable file cabinets in designated, access-controlled areas, and maintain a visitor log if off-site storage is utilized.
2. Electronic Health Record (EHR) Safeguards:
Hospices that use digital platforms must follow HIPAA Security Rule requirements to prevent breaches and unauthorized access. This includes:
Role-based access controls
Password policies and multifactor authentication
Encryption of data both in transit and at rest
Routine software updates and patches
Use of secure networks and firewalls
All EHR access should be monitored through audit logs, and any suspicious activity must be reported immediately.
3. Staff Training and Accountability:
Every employee who interacts with patient data should be trained on HIPAA privacy and security standards. This includes understanding the appropriate use of patient information, recognizing phishing attempts, and following protocols for reporting data breaches or potential threats.
4. Clear Policies and Documentation:
Establish written policies for both the protection and the retention of clinical records. These policies should clearly define:
How long records are retained
Where they are stored (on-site or off-site)
Who has access and under what circumstances
Procedures to follow in the event of closure or disaster recovery
Steps for secure destruction once retention periods expire
Review and update these policies regularly to align with any updates in federal or state regulations.
5. Preparing for Closure or Transition:
If a hospice plans to cease operations or transfer ownership, record retention doesn’t end with closure. You are legally responsible for notifying the State agency and CMS location with the exact details of where patient records will be stored, for how long, and how they can be accessed if needed. A designated contact person should also be identified to manage any future inquiries or record requests.
Staying Compliant with Recordkeeping Standards
Keeping up with ever-changing regulatory requirements can be overwhelming, especially when managing clinical operations, audits, and patient care. That’s where HealthBridge can help.
Our expert consultants ensure your hospice has the right policies in place to protect patient information, store clinical records securely, and maintain full compliance with both federal and state laws. From HIPAA training to mock audits, we offer tailored solutions that keep your facility up to date and audit-ready.
Stay compliant. Stay protected. Let HealthBridge guide the way.
