Protecting Patient Information after a Facility Closure. Appendix D: Health Information Management Checklist for Acquisitions and Closures (2011 update)

This document is intended to be used as a guide and is not intended to be all-inclusive. It should be adapted to the setting or organization type.

Purpose: To ensure appropriate health information management tasks are processed during the acquisition, closure, or dissolution of an organization's or provider's health records.

Departments: Health information management, information systems, medical staff, business office, human resources

Records Custodian:

For a provider who has died, list name of the legal representative:

Items Needed
Internal Project Team

Internal Contact List (phone, extension)

Project Lead

Project Timeline

External Contacts List

Confidentiality Agreements

Conflict of Interest

Consultant (if required)

Acquisition or Closure Documents

Business Associate Documents

Meeting Notes

Other


Question or Task

Responsible Party

Completion Date

Comment

What is the date of the acquisition or closure?

Who will review federal guidelines?

Who will review state guidelines?

Who will review medical staff rules and regulations?

Does an accrediting body require notification?

Locations of records

Location A (office)

Location B (off-site storage)

Location C (other)

What are the retention guidelines for adult records?

What are the retention guidelines for pediatric records?

Will records be transferred to another provider or organization?

If yes, on what date?

If yes, provide name, address, phone number.

If yes, who is the sender contact?

If yes, who is the receiver contact?

Who will inventory records to be sent?

When is the inventory due?

What will the inventory include?

Will records need to be retrieved from multiple locations?

Are all records complete?

If no, when are records to be completed?

Who is responsible for ensuring records are completed?

Will records be transferred to a storage facility?

If yes, on what date?

If yes, provide name, address, phone number.

Has business associate agreement (BAA) been signed?

If yes, who is the sender contact?

If yes, who is the receiver contact?

Is the receiving facility capable of handling protected health information?

Are staff at the receiving facility trained for maintaining and releasing protected health information?

If no, who will provide the training?

Will the sending organization continue to have access to records?

If yes, for what time period?

Are boxes required?

If yes, order by what date?

Who is responsible for boxing and inventorying records?

Do records need to be destroyed before acquisition or closure?

If yes, will destruction be completed by a third party?

If yes, is a BAA needed?

BAA required by what date?

What date will the records be destroyed?

By what means will the records be destroyed?

Has the destruction method been verified to be HIPAA compliant?

Who will purge the records for destruction?

By what date?

Who will certify destruction method?

Who will approve destruction requests?

What types of media are records currently in?

Paper

CD or disk

Magnetic tape

Electronic

Other

Which media will be transferred?

Paper

CD or disk

Magnetic tape

Electronic

Other

Which media will be destroyed?

Paper

CD or disk

Magnetic tape

Electronic

Other

Who will post media notices?

By what date?

Location

Location

Location

Who will handle requests for copies of health records?

In what format will records be released (paper, electronic, CD)?

When will patient notice be posted?

How long will patients have to request records?

How will legal requests during this transition be handled?

Has a records inventory been completed within the last year?

Will a records inventory be required before acquisition or closure?

Who is responsible for records inventory?

Are any records currently involved in litigation?

Who will notify legal counsel?

How will opposing counsel be notified?

Who will be responsible for these records until the acquisition or closure?

Who will be responsible for these records after the acquisition or closure?

Electronic health records (EHRs)

What is the sending organization systems?

System A:

System B:

System C:

System D:

Other:

What is the receiving organization system?

System A:

System B:

System C:

System D:

Are EHR systems compatible?

If yes, will records be transferred electronically?

If no, how will records be transferred?

Are legacy systems required for record retention?

If yes, which systems?

Will system access be required for the receiving organization?

If yes, who will authorize?

Will any information be e-mailed?

If yes, are proper security protocols in place?

Are there system archives or back-ups to inventory?

If yes, what are the locations?

If yes, in what format?

If yes, will these be transferred or destroyed?

Who is responsible for maintaining?

Has all billing been completed?

If no, when is expected due date?

Budgetary Needs

Labor (including outside consultant, if appropriate)

Copy equipment

Copy supplies

Postage

Telephone

Utilities

Transportation costs (to receiving organization or storage facility)

Storage costs (paper and electronic)

Retrieval costs (from storage facility)

Destruction costs

Notification costs

Legal counsel

Consultation fees

Software fees (e.g., conversion or archive costs)

Other:

Other:


Article citation:
AHIMA. "Protecting Patient Information after a Facility Closure. Appendix D: Health Information Management Checklist for Acquisitions and Closures (2011 update)." Journal of AHIMA (Updated August 2011).