4 Maintaining Accurate and Secure Records

Why records management matters

Good records help a practice team understand what occurred, support consistent care, and identify follow-up needs. They are useful only if they can be found, trusted, and accessed by the right people. The Record life cycle includes creation, organization, use, storage, retention, and authorized disposition.

Organize records consistently

Use the organization’s approved system and a consistent filing structure. Records may be organized by client or participant, date, service, or another approved identifier. Clear organization and consistent naming make records easier to retrieve and reduce the risk of placing information in the wrong file.

Follow the organization’s naming rules. For example, an electronic file name might include a client code, session date, and record type. Avoid unnecessary sensitive details in file names. Keep related records together or link them through the approved system; do not make unofficial copies or save records in personal accounts, unapproved devices, or informal folders. When transferring or filing a record, check that it is associated with the correct person and date.

Document and correct records accurately

Complete documentation promptly, using clear, factual, and professional language. Distinguish direct observations from information someone reported and from inferences. Include relevant information—such as the date, session context, observations, actions taken, and follow-up needs—in the required format. Avoid vague, judgmental, or speculative wording.

If an entry needs correction, follow the organization’s correction process so both the original information and the change remain traceable. Do not erase, obscure, backdate, or silently overwrite an entry. In an electronic system, use its correction or addendum function when available. An Addendum can identify the earlier entry, state the correction, and show when and by whom the update was made.

Protect records and limit access

Protect confidentiality, integrity, and availability: keep records private, prevent unauthorized changes or loss, and ensure authorized staff can access them when needed. Use only approved systems and storage locations. Secure paper files in restricted areas; protect electronic records with individual accounts, strong authentication, role-based access, and approved security features.

Lock screens when stepping away, keep printed material out of public view, and use approved secure methods when sending records. Do not share passwords or discuss identifiable information where others may overhear.

Access records only for an Authorized work purpose and only to the extent needed for that purpose. Privacy requirements vary by setting and record type. For example, HIPAA applies to covered entities and business associates, not automatically to every organization. Follow applicable law, organizational policy, and any required consent or authorization.

If information is lost, misdirected, exposed, or accessed improperly, report it promptly through the organization’s incident-reporting process. Do not conceal the issue or try to resolve it independently.

Retain and dispose of records properly

Keep records for the period required by applicable law, regulation, contract, and the organization’s Retention schedule. No single retention period applies to every record type or setting. Do not destroy records merely because they seem old or are no longer used day to day. Check the schedule and ask the records manager or supervisor if the correct period or disposition is unclear.

Pause routine destruction when a Legal hold, investigation, audit, or other preservation instruction applies. When records are eligible for Disposition, follow the approved process: securely destroy confidential paper and electronic copies, or transfer records when required. Document disposition if policy requires it. Review and update retention schedules when rules, organizational needs, or record systems change.

Check records before filing

Before finalizing a record, confirm that it is accurate, dated, complete enough for its purpose, linked to the correct person, and stored in the approved location. Check that access is appropriately restricted and that any correction or follow-up is documented. When requirements are uncertain, consult a supervisor or records-management lead rather than guessing.