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The thoroughness of medical record charting and documentation has significant impact on protecting the medical licenses of California physicians and surgeons licensed by the Medical Board of California. 

Consider the following fictionalized vignette:

Ima Doc is a physician in California who has had a thriving practice in Obstetrics and Gynecology for 15 years. She has a full patient caseload and has decided to cut back on her number of patients in order to spend more time with her family. She decides to close her obstetrics practice to concentrate solely on her gynecology practice. Three months before closing her OB practice, Ima notifies all of her patients in writing of her decision. Her termination letter includes the last day she will be available to provide OB medical care, a reminder to renew necessary prescriptions, the names of three other referral OB physicians including a medical records transfer authorization form, and information on where patient medical records are stored and how to access them. Ima sends these letters by certified mail, return receipt requested. Ima has always kept detailed patient charts after every appointment and now takes care to include the return receipt in each patient chart. In order to inform inactive patients, Ima also places an advertisement about closing her practice in her local newspaper. Two days after Ima has closed her OB practice, Ima’s GYN office receives a call from one of Ima’s former OB patients, a pregnant woman named Ura Patient. Ura is in labor and is requesting that Ima come to the hospital to deliver her baby. Ima gently reminds Ura that she has closed her OB practice and refers her to Ima’s trusted colleague. Ura becomes irate and hangs up. Ima later receives notice from the Medical Board of California (MBC) that Ura has filed a complaint against her for unprofessional conduct and patient abandonment. Ura’s medical record is requested with a written summary of care, and Ima’s career and reputation are threatened.

The above example underlines the importance of establishing and following proper patient charting guidelines as a physician. Keeping detailed patient charts protects both patient and physician, yet some physicians still choose either not to chart or to chart very briefly.

Patient charts benefit the physician by providing:

• Proof of the standard of care in the event that a patient’s medical record is requested, such as by the patient or by the Board after receiving a complaint.

• Protection against insurance company or Medicare audits.

• Protection in the event of catastrophic loss such as theft, fire, earthquake.

• Proof of continuity of care to a patient when a patient is referred to another professional, when a considerable period of time elapses between patient appointments, or if a patient is transferred to a different physician in the event of the unanticipated death/illness of the original physician.

• Protection in the event of legal proceedings between physician and patient.

• Protection against charting or billing errors.

Patient charts benefit the patient by providing:

• Treatment details for third-party reimbursement.

• Reminders to the practitioner of a patient’s medical history and treatment plan.

• Continuity of care to the patient when a patient is referred to another professional, when a considerable period of time elapses between patient appointments, or if a patient is transferred to a different physician in the event of the unanticipated death/illness of the original physician.

The duty to maintain complete patient files is regulated by federal and state laws in addition to professional licensing boards and benefits both physician and patient.

So why do some physicians choose either not to chart or to keep minimal documentation?

Some physicians believe that a wellness visit does not require charting. Others reason that there is not enough time between patient appointments to chart in addition to tending to one’s personal needs such as grabbing a quick bite or returning patient calls. Some may believe that keeping records could violate a client’s confidentiality if records are sought by third parties, such as insurers. Others feel there is nothing new to add to a patient’s chart after every appointment. Some erroneously assume that disciplinary action will never occur to them and, if it ever did, mistakenly believe that patient records could be cobbled together at that time. Some physicians also believe that they will accurately remember relevant case details if ever needed, but it is important to note that a complaint may take several months to review and/or resolve.

Details within a patient’s file are of critical importance when a licensing board decides whether to pursue disciplinary action after receiving a patient’s complaint. If it’s not in the record, it didn’t happen. Physicians must understand the laws, standards, and state licensing board requirements pertaining to patient medical records. If you have contact with a patient, document it in the patient’s chart.

Medical License Violations: We are here to help

If you are a physician or surgeon facing disciplinary action by the California Board of Medicine, it is imperative to enlist the assistance of an experienced licensing attorney at the earliest stage of the disciplinary process. The Law Offices of Lucy S. McAllister are here to help. We understand the unique legal complexities facing physicians. We have the knowledge and experience to craft a comprehensive strategy and are dedicated to navigating your specific case through the disciplinary process to best defend your professional interests.

The Law Offices of Lucy S. McAllister have successfully represented a wide range of California licensed professionals including physicians, nurses, dentists, pharmacists, chiropractors, and mental health practitioners. We are experienced in handling all types of licensing issues. Let us help you protect your professional license, your reputation, and your livelihood.

For additional information or to schedule a consultation on a professional licensing issue, please contact us today at (877) 280-9944.

Disclaimer: This article is intended for educational purposes only and does not constitute specific legal advice or outcome guarantees. This article does not establish an attorney-client relationship between you and the blog/website publisher and should not be used as a substitute for legal advice from a licensed professional attorney.

For Additional Information

The Medical Board of California – Consumer Information

Medical Board of California – Terminating/Severing Physician/Patient Relationship

Closing Your Medical Practice – Medical Board of California

Complaint Review Process – Medical Board of California