Medical Office and Clinic Records
Most medical practices have changed dramatically in the last 10 years. Their patient panels turn over rapidly, they no longer control referrals to specialists, and they are treating sicker patients in the office because of the pressure to keep patients out of the hospital. Malpractice risks have not changed in the last decade, but the risk of being prosecuted for billing fraud has gone from negligible to significant. Yet, with all the changes, many medical care practitioners keep patient medical records in a manner that assumes that they know each patient personally and that the patient will be there forever—records that would not look out of place in an office of 50 years ago.
The Joint Commission provides detailed requirements for the maintenance of medical records in the hospital and in ambulatory care centers. There are no corresponding, uniformly recognized standards for physician’s office records. Consequently, there is a tremendous variation in the quality of physicians’ office records. Physicians should use a standard medical record format such as the problem-oriented medical record for all their medical records. Whereas the Joint Commission does not certify physician’s offices, the standards for ambulatory care centers provide useful guidance for records management in the physician’s office. [Standards for Ambulatory Care. Oak Brook, IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.]