Our appreciation goes out to all healthcare professionals on the front line and our sincerest thoughts are with our community both locally and afar. During these unprecedented times, The Law Office of Nicole Irmer, as an essential business, remains open and available to help. If you need assistance maintaining or applying for a professional license, of if you have been contacted by a Board or DCA investigator, please do not hesitate to contact us at (619) 237-6130.

Don’t Let Medical Record Mistakes Sink Your Career

Posted in Medical Malpractice

Medical Record Mistakes

On an average day, a healthcare professional will see patients, catch up on the latest research, and spend time doing administrative tasks. In particular, doctors, dentists, nurses, and other healthcare workers find themselves spending a substantial amount of time doing charts. This can often seem burdensome, as well as a distraction from patient care.

Keeping accurate, thorough medical records may seem like a chore, but it is critical to any medical practice. Not only is medical documentation necessary to properly take care of your patients, but it is vital to protecting your license and your livelihood. Deficiencies in medical record-keeping can be disastrous in the event of an action by the Medical Board.

In California, medical records must contain a range of information related to the diagnosis, treatment, and care of patients. Failure to maintain these records in accordance with the law may lead to probation or even revocation of your license. Licensing Boards adopt the position that “if it’s not in the chart, it did not happen.” However, with the assistance of an experienced San Diego healthcare license defense attorney, you may be able to resolve an investigation into medical record-keeping errors with a citation, fine, and/or corrective action.

What Must Be in Your Medical Records

Under California law, patient records include records in any form that are maintained by a health care provider related to the health history, diagnosis, or condition of a patient, or to the treatment provided or proposed to be provided to the patient. If a doctor fails to keep accurate, adequate records, it may be considered unprofessional conduct.

There are several categories of information that must be contained in inpatient medical records. First, these records should contain information related to the patient’s condition and treatment, along with any explanation provided to the patient. At a minimum, records should contain:

  • Documentation of physical examination;
  • Clinical findings;
  • Vital signs;
  • Mental status examination;
  • Laboratory tests;
  • Follow-up and treatment plans;
  • Informed consent regarding the benefits and risks of treatment; and
  • Orders regarding prescription and/or treatment/care.

But complete charting must also contain additional information relevant to patient care, including:

  • Justification for treatment;
  • Consultation with the patient to inform them of their condition, any intended procedures, risks and hazards of those procedures, and alternative therapies;
  • Instructions were given to a patient by telephone;
  • Cautions regarding prescription medication that may interfere with the patient’s ability to work or to drive safely;
  • Notations on allergies or sensitivities;
  • Surgical records that are both comprehensive and promptly dictated or written;
  • Instructions to patients on follow up care;
  • Pre and post-operative information; and
  • Pathology and x-ray reports

If a healthcare provider makes a technical error in these records, it should be corrected by drawing a line through the relevant section, writing a correction in the margin, and signing and dating the record. Erasing errors could lead to a charge of alteration of medical records, which may lead to both civil liability as well as disciplinary action.

Third, when prescribing controlled substances, medical records must be incredibly detailed. Both federal and state laws require manufacturers, wholesalers, pharmacies, hospitals, physicians, and dentists to maintain an inventory of all drugs that are ordered, purchased, distributed, or dispensed. Records of prescriptions for Schedule II controlled substances must be maintained for a period of three years.

There are a number of laws related to the retention of medical records depending on the specific situation (such as patients who insured via Medi-Cal or whose care was paid out of the Emergency Medical Services Fund). Generally, medical records should be retained indefinitely for patients who are under active treatment. At a minimum, patient records should be maintained for at least seven years, but may be longer depending on additional factors.

Corrective Actions for Medical Record Documentation Errors

As noted above, a failure to maintain accurate and adequate records constitutes unprofessional conduct under California law. The Medical Board of California recommends a minimum of 5 years of probation (stayed revocation) and a maximum penalty of revocation for this offense. If the complaint involves repeated acts with one patient, a public reprimand may be ordered in lieu of probation or revocation. 

Depending on the specific facts of your case, there may be an opportunity to resolve a complaint regarding medical record documentation before a formal Accusation is filed against you by the Medical Board of California, the Dental Board of California, the Board of Registered Nursing, or another healthcare professional licensing board. A skilled San Diego healthcare license defense attorney can develop a comprehensive strategy to defend your license and your livelihood.

As soon as you learn of an investigation or complaint against you for medical record errors, your first step should be to reach out to an experienced lawyer. An investigation by one of these boards or the California Department of Consumer Affairs (DCA) is a formal process that may result in disciplinary action and even criminal charges. Your attorney can perform a thorough investigation and put together a plan to resolve the matter in the most favorable way possible, which may include having the investigation closed without discipline.

In certain situations, your licensing board may recommend corrective action instead of filing a formal Accusation against you if investigators determine that a minor violation of the law has occurred or that the complaint may be mediated. For medical record errors, you may be required to take a remedial course or a Continuing Medical Education (CME) on medical record keeping. You may also be issued an administrative citation and a fine.

The most critical time of the disciplinary process is the investigation stage. At this point, your healthcare license defense attorney can advocate for you, presenting mitigating evidence to investigators and making an argument for corrective action rather than a formal Accusation and disciplinary action. That is why it is so important to contact a lawyer immediately after learning about a complaint or investigation against you.

Facing a Medical Records Investigation? We Can Help

As a medical professional, you devote your days to providing the highest quality of care to your patients. Taking time out of a hectic workday to thoroughly document patient care may not seem necessary. Yet failure to accurately and adequately maintain patient medical records can result in disciplinary action against you.

At the Law Office of Nicole Irmer, we have substantial experience representing doctors, dentists, nurses, and other healthcare professionals in all stages of the disciplinary process. We utilize our knowledge of the law and our negotiating skills to help our clients achieve the best possible outcome for their case. For a confidential, no-risk discussion of your legal options with a compassionate San Diego healthcare license defense attorney, call us right away at (619) 237-6310 or email us at any time.