Why Is It Important to Keep Proper Medical Records?

As a medical professional, it is important that you keep proper medical records for your patients. Though it may seem like a time-consuming task, it is absolutely necessary, as failure to do so is considered professional misconduct. Read on to discover why it is important to keep proper medical records and how one of the seasoned New York physician defense lawyers at Walker Medical Law can offer you assistance.

Why is it important to keep proper medical records for my patients?

One way you can get yourself to keep up with your patient’s medical records is by always assuming that somebody else is going to be reviewing those records at some point. And with this review, this someone should be able to decipher exactly what your patient’s medical conditions are. And so, in addition to keeping up with these records, you must ensure that these records are as clear as possible.

With that being said, important facets to keep in your patient’s medical records are as follows:

  • Notes regarding your patient’s complete medical history.
  • Notes regarding your patient’s physical examination(s).
  • Notes regarding your patient’s diagnosis.
  • Notes regarding your patient’s treatment plan.

If you do not follow through on this, you may be hearing from the New York State Department of Health’s Office of Professional Medical Conduct (OPMC) or the Office of Professional Discipline (OPD). And if, after reviewing your patient’s medical records, they conclude that you have been negligent with their upkeep, then they may accuse you of professional misconduct. With this comes its own set of serious consequences.

What should I do if I am accused of keeping improper medical records?

Say, for example, that your patient receives a medical bill after their treatment plan has been completed. Your patient may have questions as to what you billed for and ask for you to justify your charge. If you do not keep up with the proper documentation in your patient’s medical records, then you may not be able to justify the items or services for which you billed them for. Ultimately, you may have to pay this money back to your patient.

All in all, good documentation is important to protect you from liability, accusations of fraud, or accusations of abuse. But if you have the OPMC or the OPD after you, then you must properly prepare to go on the defense with one of the competent New York physician defense lawyers from our firm. You should not have to go through questioning or a hearing alone, so pick up the phone and give us a call today.