Medical Records
Improper medical records can subject medical care practitioners to civil and criminal liability.
Medical records must meet federal standards for documentation.
Even informal medical encounters should be documented.
Patient confidentiality must be respected when releasing medical records.
Medical records must never be altered or fabricated.
Traditionally, there were two major legal issues in medical records management: how would the medical record be used in possible medical malpractice litigation; and who should have access to the record. These are still important issues, with access having become even more difficult a problem in the face of managed care and electronic records. A third problem has now arisen from the growing concern with insurance fraud: does the record contain the necessary information to justify the bill for services rendered, and to prove that they were appropriate services for the patient's condition. Failing to meet these standards can delay or prevent payment on insurance claims, and, in the extreme case, result in criminal prosecution or substantial civil fines.
This section deals primarily with medical office and clinic records, rather than hospital records. Hospital records are governed and audited by many organizations, with the most common being the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) . Most state laws and regulations also apply to hospital records. In contrast, relatively little attention has been paid to medical office records, at least until the Office of the Inspector General (OIG) began to audit them as part of Medicare/Medicaid fraud prosecutions. With the increasing pressure to keep patients out of the hospital, and to do as much care as possible in the medical office, practitioner records contain the greatest share of modern medical information.