Lorman Education Services - Medical Records as a Defense to Your License
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Transcript of Lorman Education Services - Medical Records as a Defense to Your License
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Medical Records as a Defense to your License to Practice Your Profession
Steven L. Simas, Esq.
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Steven L. Simas Experience
Simas & Associates, Ltd. –2002 to present Deputy Attorney General, Office of the Attorney General California Academy of Attorneys for Health Care Professionals Legal Counsel, California Physical Therapy Association Legal Counsel, California Registered Veterinary Technician Association
Practice Areas Health Care Law Professional Licensing and Regulation Civil Litigation and Appeals Employment Law and Workplace Regulation
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Medical Board and Other Agencies’ Expectations for Recordkeeping
Part I:
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Medical Board’s Standards for Medical Recordkeeping
Medical Practice Act –Business & Professions Code §2266 provides: The failure of a physician and surgeon to maintain adequate
and accurate records relating to the provision of services to their patients constitutes unprofessional conduct.
What is “adequate and accurate”?
Depends upon clinical circumstances
Matter of expert opinion
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Medical Board’s Standards for Medical Recordkeeping A Comprehensive Patient Record Contains:Patient’s condition and treatment Any consultation informing the patient of his or her conditionDiscussion of intended procedures, risks, hazards, and alternative therapyAny instructions given to a patient by telephone
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Medical Board’s Standards for Medical Recordkeeping Any cautions regarding prescription drugs that may
interfere with a patient’s occupation or driving safely Special note should be made of any allergies or
sensitivities Surgical records which are comprehensive and
promptly dictated or written. The anesthetist should record both pre- and post-operative information.
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Medical Board’s Standards for Medical Recordkeeping Instructions to patients on follow-up care. Pathology and X-ray reports. The justification for treatment.
Source: Guide to the Laws of Practicing Medicine by Physicians and Surgeons, Sixth Edition, 2010, Medical Board of California (http://www.mbc.ca.gov/publications/laws_guide.pdf)
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Contrast: The Physical Therapy Board’s Standards for Recordkeeping Unlike the Medical Board, this is governed
by Physical Therapy Board Regulation: Title 16, Cal. Code Regs. § 1398.13 provides that a
physical therapist shall document and sign specific things in the patient record.
Like the Medical Board, failure to do so can be “unprofessional conduct.” (Bus. & Prof. Code § 2660(i)).
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Contrast: The Physical Therapy Board’s Standards for Recordkeeping Board Regulation 1398.13 requires the following to be
documented in the record:(1) Examination and re-examination (2) Evaluation and reevaluation (3) Diagnosis (4) Prognosis and intervention (5) Treatment plan and modification of the plan of care (6) Each treatment provided by the physical therapist or a
physical therapy aide (7) Discharge Summary
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Contrast: The Physical Therapy Board’s Standards for Recordkeeping Contrast with Medical Board record
requirements: PT Board does not rely upon standard of care
Very specific requirements
Does not rely upon “expert testimony” to determine violation
More objective?
More nitpicky
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Medical Board’s Standards for Medical Recordkeeping
Lessons and Final Thoughts What is a “complete” or legal medical record depends upon
the profession of the health care provider
Proper records can be the subject of an expert opinion
Some licensing boards have very specific requirements
Failure to keep proper records is “unprofessional conduct” for most licensed health care providers
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How Licensing agencies build cases upon medical records
Part II:
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How Licensing Agencies Build Cases Upon Medical Records
After a licensing board receives a formal complaint or has other reason to investigate, it has the following tools to do so: Subpoenas Release from complaining party Interviews Hospital records
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How Licensing Agencies Build Cases Upon Medical Records Subpoenas: Under the Administrative Procedure Act (Govt. Code § 11180), the
head of each department may issue a subpoena to investigate:
All matters relating to the business activities and subjects of the department's jurisdiction;
The violation of any law or any rule or order of the department; and
Any other matter that some rule of law authorizes the department to investigate.
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How Licensing Agencies Build Cases Upon Medical Records Other methods of licensing Boards obtaining records:
Release from complaining party or patient (often without licensee’s knowledge)
805 Reports/Peer review reports Reports of Settlement Hospital records
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Accusations and Citations For Improper Recordkeeping
Part III:
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Accusations and Citations For Improper Recordkeeping Licensing Board actions against health care professionals
Accusations Citations
Recordkeeping violations (grounds for license discipline) Failure to keep “adequate” records Failure to keep records Failure to document treatment in the records Failure to document things required by Board (e.g. discharge
summary for PT Board)
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Accusations and Citations For Improper Recordkeeping How recordkeeping problems manifest in a
licensing hearing: The Golden Rule : “If it is not in the record, it did not
happen”Difficult patientReferralsHistory & PhysicalPrescribing casesPain management
Medical records and use of experts in licensing defense cases
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Accusations and Citations For Improper Recordkeeping
If the licensee met the standard of care, it must be in the record
Defensive recordkeeping
Can be the difference between a finding of negligence or not
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Accusations and Citations For Improper Recordkeeping Medical records and use of experts in licensing
defense cases Medical records are the tool of the expert
witnesses Board experts look first at medical records Medical records can cause license discipline or
other issues even if care was proper
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Accusations and Citations For Improper Recordkeeping Examples
Veterinary Board overnight hospitalization case
Overnight monitoring not in record
Veterinarian provided uncontroverted testimony
ALJ found “no overnight monitoring”
Vision insurance audit
All information regarding charges was in record
Auditors could not find it
Finding “optometrist sent in incorrect and unjustified charges”
Medical Board LASIK case
Informed consent records
“Eval” versus “Reeval” in cataract case
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Steven L. Simas, Esq.SIMAS & ASSOCIATES, Ltd.
Government & Administrative LawSacramento -916.789.9800
San Luis Obispo -805.547.9300
www.simasgovlaw.com