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.