Hospital Medical Records
Each hospital has its own rules for maintaining medical records. Most of these derive from the standards set by the Joint Commission, which provide a detailed guide to keeping records. Medical care practitioners who practice in hospitals should become familiar with these rules. Under recent regulations from the OIG, hospitals are now required to audit chart entries to assure that they meet the standards for Medicare/Medicaid billing. These regulations also extend to outpatient clinics run by the hospital, or in which the hospital has an interest. Unlike failure to comply with Joint Commission medical records rules, which usually only merits a slap on the wrist, failure to comply with Medicare/Medicaid rules will require the facility to dismiss the medical care practitioner or face federal fraud charges on the bills submitted for improperly documented care.