Your medical record keeping is always an issue for the Department of Health or the Department of Education. The reason for it is that it’s unprofessional conduct if you do not keep a proper medical record. When I say a proper medical record, they want a complete history, they want a physical examination, they want a diagnosis, and they want treatment. They want that to be clear on your medical records. If you don’t do this, they will possibly say that you have committed unprofessional conduct, and that is never a good thing for you.
You have to be very careful that your records withstand scrutiny. When you write your records, just assume that someone is looking at them later on and wants to be able to tell, just by looking at your records, what was wrong with this patient, what your exam showed, and what your treatment discussion was. If you look at your records and you determine for yourself that no one could ever figure those things out, you have got to change. If they review this record, your records, they will come to the conclusion that you’re not keeping proper records. While this is certainly a time-consuming situation, it’s absolutely a mandatory one. Do not let yourself get into this situation.
This informational blog post was brought to you by Paul E. Walker, an experienced New York Medical Malpractice Defense Attorney.
