Documentation is a critical aspect of any medical practice. The original and primary purpose of maintaining clear, accurate and complete medical records is for the protection of your patients. However, in today's world, documentation is also a crucial aspect of any medical malpractice case. This month, I hope to answer some commonly asked questions about medical records, and then expand into the world of electronic health records next month.
How much charting is necessary for protection?
Good charting does not need to be excessive. There should be enough information to prove that you have met the standard of care protocols, while justifying your decisions on providing, delaying or changing treatment. Aside from your history of treatment and test results, the chart should also include any patient complaints or concerns. Patient history should also include any drug or food allergies and final results of any prior tests and treatments.
When should I update records?
Most physicians prefer to make entries at the end of each visit with a patient. Some choose to make their entries at the end of the day. I believe the best time is during or immediately after each patient visit. At the end of the day, you could forget about some items that should be entered and there is always the possibility of interruption or delay.
Is it OK to use shorthand?
Shorthand notes and abbreviations may seem to be sufficient at the time; however, such notes may be difficult to decipher and recall years later. Charts should be concise and clear in order to confirm to a jury the level of care provided. If you cannot remember or the jury cannot understand, your defense could be in jeopardy.
How long do I need to maintain patient records?
In a word - forever. Unless advised differently by your attorney, patient charts, x-rays, test results and medical correspondence should be stored forever.
What if my files are lost or destroyed?
Such a loss would definitely create problems for both you and your patients, but it is unlikely that you would be held liable for such a catastrophic loss, unless it was due to negligence on the part of yourself or your staff. Although not a legal requirement, it is always a good idea to maintain some sort of backup storage in a different location.
How would lost records affect a malpractice case?
Generally, under the "missing evidence" principle, judges will instruct juries that lost records, without an adequate explanation for the loss, can be presumed to be damaging to the case. However, in cases of catastrophic loss, it is unlikely that the "missing evidence" rule would apply.
What about billing records, telephone calls and appointment books?
Billing records, according to IRS guidelines, should be kept for 7 years in a separate accounting file. Telephone calls and messages, relating to medical care, should be documented in the medical records. Appointment books should be kept for one year.
If a new patient brings past medical records, what is my responsibility?
You should review all of the documents, extract or photocopy any pertinent records, and then return the original documents to the patient. Anything you retain should become part of their permanent medical record in your office.
What is the best method of storage?
Computer data should be backed up at regular intervals and, as mentioned before, stored off-site as well. Inactive records, relegated to long-term storage, should be stored in such a way as to protect privacy, safeguard the records from natural disasters, and allow for easy retrieval when needed.
What if I close my practice?
You are responsible for making appropriate arrangements for the disposition of medical files. Plus, remember that the possibility of a lawsuit continues to exist after a practice is closed. (California recommends that records must be retained for at least 25 years after the patient's last visit.) If you are selling or transferring your practice, there should be a custodial agreement stipulating the recommended retention time and access.
What is the best method for destroying records?
Paper records should be destroyed by incineration or shredding. The best method for destruction of electronic records has not yet been determined, although some say that it requires the demolition of the hard drive on which they are stored.
Medical records are essential to your defense in the event of a malpractice claim. These are just some basic guidelines to help you manage your risk, protection, and defense. Treat them accordingly.
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