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Employee Files & What to Do With Them

By: Valery Bond, RHIT

As healthcare professionals, we take pride and care in the detail in maintaining our employee files.  Certain items must be separated from the others, files securely locked and out of reach from co-workers hands.  Personnel’s personal information must be protected.  We all know these things and probably already have a procedure in place for compliance.

Whether your facility has been deemed accredited (Joint Commission, for example) or just starting up, employee files must be maintained, reviewed, audited, and kept according to retention requirements.  Knowing which laws apply aids in keeping your business compliant.  For example, pursuant to ERISA laws, there is no specific time period to maintain records that reflect age, marital status and/or service records.  The Social Security Acts states that employees’ social security numbers must be kept four years from the tax due date or payment of tax, whichever is later.  So, there’s a lot of tracking going on.

Human Resources, or sometimes known as Human Capital, plays a large role in the healthcare arena.  Whether your practice or facility has an HR Director or your Office Manager maintains employee files, it is a large, accountable responsibility.   Electronic or paper records must contain specific documents under federal laws.  If your files are electronic, you already know that the W-4, I-9 forms and job descriptions are signed, dated and scanned into the e-file.  Basic information can be kept on a form and still complies with federal law, such as the employee’s full name, number (if used), address, birth date, gender, job title, and payroll information.  Considering to keep records required by law separate from the personnel file make it easy to produce if requested.

Scheduling annual audits to occur the same week of the same month every year is one way to get into a healthy habit of auditing files.  Efficiently setting up employee files for easy audit and maintenance is imperative to a successful, compliant organization.  Knowing what stays in the personnel file and what is to be separated should be on a checklist to be used upon new hire and annual audits.   One area that is missed quite often is monthly tracking of healthcare professionals’ license status.  Although the person responsible for this task may verify active licensure, printing and keeping the dated document in that employee record validates the active license; and hopefully, indicates that there were no deficiencies or conditions linked to that employee.  Consider scheduling a monthly licensure check the first week of every month.

Most employers have three or four different files or e-records:  the main personnel file, medical file, nonjob-related or confidential information such as wage garnishments, and payroll records.  Your employee’s medical file is separate from the file that contains their job description, offer letter, etc. and HIPAA protected.  Employee’s training, education and/or in-service attendance logs must also be maintained in the employee’s personnel file and also in a separate education/in-service log book.

Both paper and e-records are not accessible to all; and, who would want them to be?  There are no federal laws dictating who gets access to an employee file, but some states have passed laws that limit or regulate employee access files.  In Florida, it depends on the type of employment.  Public employees can make a public request for their file through the Freedom of Information Act, but private employers may have, and usually do, another policy and process.  The law gives the employee the right to request their file, but the employer may refuse access, especially if that employee is being considered for termination and documents to that affect are in that file.  Supervisors and Managers may have access to employee files, as well as Human Resources; or as I like to say, Human Capital representatives.

Knowing what belongs in whose file is key to successful healthcare employee record management and always maintaining a “Survey Ready” agency.  Join me May 24th at 12:00 EST for a webinar concerning your medical practice’s employee files. Registration HERE.