Medical Charts

When you are audited by an insurance company, they ask you for copies of your charts. When you are sued for medical malpractice, they ask you for copies of your charts. When Medicare conducts a peer review, they ask for a copy of your charts. When the Office of Professional Medical Conduct is conducting an investigation, they ask for copies of your charts. The quality and content your charts will usually be one of the predominate factors in whether you have to pay back a lot of money to a carrier, lose in court, be removed from the Medicare program or lose your license. I have not even touched upon the importance of accurate and complete charting in improving your patient care and reducing medical errors.

Your chart is your contemporaneous evidence of what you; the physician did for your patient. It is the single most important piece of evidence the physician has to defend himself. An accurate, complete chart gives your health care attorney the material to work with to mount a credible defense of your license, your integrity and your wallet.

Your chart is the only written evidence of your justification of the diagnosis you made and the reason and efficacy of the treatment you prescribed. Get it right the first time! Here is a short list of "Do's and Don'ts

• i. Do keep well-documented and legible medical charts as they can assist in a doctor's defense in a legal action and protect a doctor from potential liability

• ii. Don't destroy, lose, or alter an original record as this can be interpreted as an attempt to conceal misconduct and can plant a seed for investigation

• iii. Don't include personal comments and observations in a medical chart as they may be offensive to a potential tribunal

• iv. Do sign and date the medical charts whenever new entries are written or changes are made

• v. Do make your charts clear for so that other members of your office can understand what you have written

• vi. Do develop a standard list of abbreviations used by your office for continuity and clarification purposes

Your chart should be legible to make it easy for all who follow to read why you did what you did and when you did it. Reviewers appreciate clarity and legibility. It puts them in a positive frame of mind. It alerts the reviewer that you, the physician, make the effort to keep records that are neat and understandable. Additionally, a legible neat chart, makes it more likely that you will not mistake the name of the prescription, the dosage, the date or whether the pain was on the right arm or left arm.

Keep your records in a safe place. You do not win points for credibility when you have to explain to a reviewer that your dog ate the records, or that they were destroyed in a flood.

You state that a patient dresses like a slob or is stupid. In effect, you have made the complainant the victim. Nobody likes that. You do not endear yourself to the jury or reviewer; besides, it is very unprofessional.

Do not even think of changing your records. Incorrect dates, inks, computers, all make it all too easy to detect such a change. Perhaps you forgot you already sent in a copy of your records to an insurance company. In any case, nothing will lose a case, your license or worse, faster than changing your chart. It is illegal and it is fraudulent. Do not do it!

Keep an alphabetical list as to what all of your abbreviations mean. Provide a copy to your attorney. Again, this will facilitate the reviewer's job.

The next question often asked if what actually comprises the physician's medical record.

Parts of a Medical Record

i. Identifying data;

ii. Chief complaint;

iii. Present illness;

iv. Detailed past medical, social and family history;

v. Physical examination and diagnosis;

vi. Clinical laboratory reports, x-ray reports, treatments and tissue reports;

vii. Notes of all telephone conversations and recommendations made;

viii.Videotapes of procedures performed and photographs of patients and

ix. X-ray reports and films, original mammography films, and electronic fetal monitor strips.

As important, the following are NOT Part of a Medical Record:

i. Personal notes and observations;

ii. Includes notes and comments on paper which are not intended to be part of the record, but NOT handwritten progress notes;

iii. Information or records from another doctor or a hospital

HOWEVER, if the patient has made a reasonable attempt to obtain the records from the original source and is unable to do so because the doctor is deceased, or has moved, or no longer has a copy of the records, the doctor MAY provide a copy and

iv. Confidential information provided by a person other than the patient which was meant to be kept in confidence and has not been disclosed to anyone else.

In conclusion, follow the above suggestions when you receive a request records. Your first call should be to your health care attorney. The proper attorney will help you dig out of any hole. Do not go it alone and dig a deeper hole. The license you save may be your own.