Medical records are an important part of a patient's care. Proper documentation throughout the course of treatment is essential. Various regulations are in place to help better ensure that medical records are in order.
What are the rules when it comes to record keeping?
These rules can vary depending on the state where the physician practices medicine. New York State requires patient records be retained for at least six years. In cases involving minors, physicians should retain the records for at least six years, or until one year after the minor patient reaches 18, whichever is longer.
In some medical malpractice cases, handwriting is often a concern. Under the regulations, "Medical records shall be legibly and accurately written." In addition, storage is also a concern. Medical records must be "complete, properly filed, retained and accessible in a manner that does not compromise the security and confidentiality of the records."
New York law also states that hospitals must have a department that is responsible for these records and that records must be easily accessible in a timely manner. The regulations also provide guidelines on the use of electronic record keeping systems.
It is important to note that federal laws may also apply. In addition to federal laws, physicians should be aware of the stance of governing medical bodies. The American Medical Association (AMA), for example, has also taken a public stance in support of the use of electronic health records.
What can physicians learn from these regulations?
The practice of medicine is a complex endeavor. Physicians may need to learn new forms of technology to use within their practice, manage their business wisely and comply with applicable regulations -- all while trying to provide quality care to the patient.
Proper record keeping may help a physician avoid, or minimize, a professional license investigation in the event that a physician's ability to meet these regulations is questioned. However, if you are a physician under investigation with regard to your record keeping, seek legal counsel. An attorney experienced in medical malpractice defense and professional licensing can advocate for your interests, working to better ensure your professional reputation is protected.