Medical records being vital with regard to provision of appropriate patient care, and also with regard to their use in medical litigation have to complete in all respects. When submitted for medical record review, inconsistencies and errors in the medical records pose serious issues. Such erratic medical records have always remained a big problem for the government, insurance companies, lawyers, physician organizations and others that have to handle these on a daily basis.
In spite of the grave consequences, many practitioners in hospitals and managed care organizations continue to disregard the rules and regulations pertaining to medical records and carry on apathetically. They wake up and complete the medical charts only when threatened by some form of disciplinary action. However, a clarification from the National Practitioner Data Bank requires physicians to keep their medical records up to date and completed. According to this, a 31-day suspension based on a practitioner’s incomplete medical records would be reportable “if the failure to complete medical records is related to the physician’s professional competence or conduct and adversely affects or could adversely affect a patient’s health or welfare.” The Data Bank has warned hospitals and other reporting entities that medical record suspensions should come under professional review actions, rather than administrative actions thus indicating the necessity of reporting. Practitioners need to take note of this.
Timely Completion of Medical Records Is Mandatory
- Hospitals participating in the Medicare program have to maintain medical records for each patient evaluated or treated at the hospital.
- Medical records have to be complete, accurate, properly filed and managed. They should be easily accessible.
- Entries have to be legible and unambiguous.
- The names and signatures of persons ordering, providing or monitoring the service provided have to be there in the records. All dates of service should be entered correctly.
- Physical examination notes including a health history performed no more than 7 days before the date of admission or within 48 hours after admission should be present.
- Medical records have to be completed within 30 days after discharge and must contain the final diagnosis.
Apart from federal regulations regarding medical record maintenance, hospitals and organizations may have their own standards as regards patient records. Ensuring that these are strictly followed is the important concern. Care providers should be aware that shabby medical record keeping and aberrant medical records can have grave legal consequences including claim denials and penalties.
