Long form retention

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dsitzes

Long form retention

Post by dsitzes » Fri Feb 28, 2014 10:38 am

FMCSA requires the medical examiner to keep the original Medical Examination Report (long form) for at least three years. Is it OK to store the form as a digital file in the electronic medical record and dispense with the original paper form, or must we retain the paper version for the full three years?

As far as I can tell, this is the pertinent DOT regulation:
(i) Each original (paper or electronic) completed Medical Examination Report...must be retained on file at the office of the medical examiner for at least 3 years from the date of examination.


http://www.fmcsa.dot.gov/rules-regulati ... reg=391.43

I have not been able to get a straight answer to this question so far.

Is the problem that of determining what the FMCSA means by "original?"

Is a scanned copy of the original paper exam form considered an electronic "original" report?

If not, what IS an "original" electronic report? Since this regulation refers to an electronic original, surely there must be such a thing?
Is an electronic version "original" only if the exam results are directly entered into a computerized version of the report form rather than on paper?

Just wondering if anyone has found the answers.



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Re: Long form retention

Post by Robert Swotinsky MD » Fri Feb 28, 2014 9:48 pm

There is no regulation or guideline about this from FMCSA.

The federal government - specifically, the Centers for Medicare and Medicaid Services - has issued guidance that an accurate, printable image from the EMR that can be promptly produced for auditing or other purposes is sufficient.

DOT still requires original hardcopy CCFs because of an interpretation some years ago that original signatures are needed for forensic integrity.

You should keep the original long forms until they are scanned. And, if you're aware an exam is likely to be litigated or otherwise challenged, it would be prudent to keep the originals until such threat has passed. Otherwise, scanning them and destroying the originals should be ok.

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