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.