Managing Your Practice, Medical Records

Medical Records Perils and Pitfalls

[Note: Special acknowledgment to William Norcross, MD, Sara Fernandez Taylor, and Timothy Blanchard, JD, MHA, for providing pertinent information and support in creating this article.]

Communication: It’s a universal skill needed by all physicians. However, when we hear this word, we immediately think of verbal interaction. Only as an afterthought do we think of the medical record as a form of communication. Nevertheless, this written form of communication is of paramount importance when dealing with both concurrent patient care and review of past care.

Patients Seeing More Than One Doctor in a Group • Requests for a Deceased Patient’s Medical Record • Blue Cross 2010 Authorizati

Dear SDCMS Office Managers,

This will be my last time writing for you in San Diego Physician. I have decided to leave my position as your office manager advocate to begin a nursing program here in San Diego. It has been my pleasure meeting many of you here at our SDCMS office manager forums as well as in your own offices.

Medical Records

QUESTION: How long should records be kept?
ANSWER: Although states may have different guidelines or laws, The Doctors Company recommends the following:

Charging for Medical Record Copies • Reporting Tuberculosis • Buying the "CPLH"

QUESTION: I have a patient whom I saw for one visit. We made plans for further care, but they decided not to go through with the procedure. Now an attorney is requesting a copy of the patient’s medical records. Can I charge this attorney, or do I have to provide these records for free?

ANSWER: According to CMA ON-CALL document #1127 (“Attorney Pre-litigation Request for Medical Information”), “All reasonable costs incurred by the physician may be charged to the person whose written authorization required the availability of the records.” This includes:

Lawyers Requesting Medical Record • Gynecology Exam Handout • DEA Agents

QUESTION: We received a request from a lawyer for one of our patients’ medical records. This lawyer also wants all of the previous records from the previous physicians that this patient had care with. We have these records in our possession because the patient provided them to us when we took over their care. Do we have to provide these records as well?

Medical Record Retention

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.