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Tips for Keeping Your Patient Records Secure

Keeping patient records secure is one of the most important parts of the administration of any private practice or healthcare business. Not only are you required to ensure the patient records are kept secure but it is one of the most important areas that you can develop trust with your clients if they know that you are strict about maintaining confidentiality with their records.

Unfortunately, there is not a lot of education around how to keep patient records secure. Those who write the guidelines around what must be done from a HIPAA requirement perspective do not provide guidance on how to keep patient records secure.

In this blog we would like to provide some of that guidance on how to make your patient records secure so that you can have the peace of mind knowing that your documentation is not going to suffer any kind of breach.

Invest in an electronic health record system

The first tip in keeping your patient records secure is to invest in an electronic health record system. Electronic health record systems have become the gold standard in security and practice management. You can find them with a quick Google search and these systems come in a wide variety of formats and prices.

It is important to pick an electronic health record system that you feel comfortable with, that fits your budget, that your staff like, and that is going to work with your patient record keeping processes. Once you have found or narrowed down the list for an electronic health record system you can then begin to explore what patient recordkeeping looks like in your practice.

Some of these systems are fully integrated which means that all patient documentation starts and ends with the electronic healthcare system. These kinds of systems are ideal because it eliminates the need for external documentation and reduces the likelihood of human error in the on-boarding process.

Regardless of the capabilities or features of your electronic healthcare record keeping system you will need to ensure the security of that system. Make sure that the electronic health record system that you hire is fully capable of making sure your client records are secure.

Lock all areas where patient records are kept

If you are a private practice that is not fully electronic and integrated within the electronic health record system and are still maintaining paper documents, you will need a procedure for locking all the areas where patient records are kept and maintained.

A common security concern is in the billing office where the electronic or paper explanation of benefits are kept. Most of the time a medical biller is busy and will leave documents on their desk but this is an unacceptable pathway if you are to maintain the security as your client records. You will need a fair amount of discipline around storage and locking of patient records if you would like to ensure that all of your records are kept safe.

Many clinicians in private practice have also had the experience of being in an institutional setting and have direct experience of watching administrative staff lock patient records at the end of day. It is a good idea to maintain that level of discipline even in your private practice.

Enable two factor authentication on all computers and phones used for patient recordkeeping

We all know that hacking and digital vulnerabilities exist even with the most sophisticated software tools. One of the easiest ways to make sure that your software tools and your digital documents are kept safe is to enable two factor authentication on all computers and phones used to interact with client information.

This is pretty simple to set up but if you need more help with this we recommend contacting the help center of the electronic health record system that you use or of the hardware company of the equipment that you use. We know that Apple and Microsoft have well established help centers and knowledge centers that will assist in setting up two factor authentication.

We also recommend setting up two factor authentication on your emails so that any hack is less likely to occur.

Train and retrain your staff on the patient record keeping procedures

One of the areas of private practice that is the most neglected is the area of training and retraining on processes and procedures. Oftentimes practice owners are busy and they don’t realize that the procedures that they set up are starting to drift into something that they did not intend. It is important to make sure that your staff are kept aware of any process changes for common procedures that you have implemented in your practice.

If you have hired new staff in the last year, which many of you likely have, it is important to make sure that those new staff are trained on your processes and procedures so that when they are operating in your practice they are doing things according to the way that you would like to be done.

One area of private practice that can’t get enough attention is recordkeeping and security within your private practice. It is very important to make sure that all of your staff are following the correct procedure in terms of recordkeeping and availability of those records.

Maintain audit schedule for your patient records to ensure compliance to your processes

If you are concerned or have a reason to be concerned that your patient records are being compromised then you can set up an audit process to ensure the availability and integrity of the patient records that you create, distribute and receive.

One way to ensure compliance is to have a sign out log if you have a patient record room. The other way to ensure compliance is to have each member of your staff sign a log form each time they interact with the documentation as a check in procedure. This provides you with an audit log to ensure you know who is interacting with documentation.

Most private practices are not at the size of larger organizations and therefore don’t have a need to audit patient records, however if you are growing and want to ensure the integrity of your recordkeeping then it would be a good idea to maintain an audit program for a short time.


Ensuring compliance of your recordkeeping procedure is not only a HIPAA requirement but it is also a requirement of your contract with insurance company and it is an ethical area of concern. It is important to build trust with the community and your clients to make sure that your patient record keeping is up-to-date. We hope that this blog was helpful for some tips around patient record cheating and we would love to hear your feedback or questions around patient record keeping.

If you would like help in ensuring the safety of your billing, Practice Solutions offers a HIPAA compliant solution to all of your insurance billing needs. Contact us and let us know what your billing needs are, and we will provide a free consultation to see if Practice Solutions might be a good fit.


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