Keeping aberrant medical records can have grave legal consequences. Care providers have to maintain accurate and properly filed medical records.

1. http://www.mosmedicalrecordreview.com/
1-800-670-2809
Incomplete and Aberrant Medical
Records – a Serious Concern
Medical records being vital with
regard to provision of appropriate
patient care, and also with regard to
their use in medical litigation have
to complete in all respects. When
submitted for medical record
review, inconsistencies and errors
in the medical records pose serious
issues. Such erratic medical records have always remained
a big problem for the government, insurance companies,
lawyers, physician organizations and others that have to
handle these on a daily basis.
In spite of the grave consequences, many practitioners in
hospitals and managed care organizations continue to
disregard the rules and regulations pertaining to medical
records and carry on apathetically. They wake up and
complete the medical charts only when threatened by some
form of disciplinary action. However, a clarification from
the National Practitioner Data Bank requires physicians to
keep their medical records up to date and completed.
According to this, a 31-day suspension based on a
practitioner’s incomplete medical records would be
reportable “if the failure to complete medical records is
related to the physician’s professional competence or
conduct and adversely affects or could adversely affect a
patient’s health or welfare.” The Data Bank has warned
hospitals and other reporting entities that medical record
suspensions should come under professional review
http://www.mosmedicalrecordreview.com/
1-800-670-2809

2. http://www.mosmedicalrecordreview.com/
1-800-670-2809
actions, rather than administrative actions thus indicating
the necessity of reporting. Practitioners need to take note of
this.
Timely Completion of Medical Records Is Mandatory
•
•
•
•
•
•
Hospitals participating in the Medicare program have
to maintain medical records for each patient evaluated
or treated at the hospital.
Medical records have to be complete, accurate,
properly filed and managed. They should be easily
accessible.
Entries have to be legible and unambiguous.
The names and signatures of persons ordering,
providing or monitoring the service provided have to
be there in the records. All dates of service should be
entered correctly.
Physical examination notes including a health history
performed no more than 7 days before the date of
admission or within 48 hours after admission should
be present.
Medical records have to be completed within 30 days
after discharge and must contain the final diagnosis.
Apart from federal regulations regarding medical record
maintenance, hospitals and organizations may have their
own standards as regards patient records. Ensuring that
these are strictly followed is the important concern. Care
providers should be aware that shabby medical record
keeping and aberrant medical records can have grave legal
consequences including claim denials and penalties.
Posted by MOS Medical Record Review Company
http://www.mosmedicalrecordreview.com/
http://www.mosmedicalrecordreview.com/
1-800-670-2809