Recordkeeping
(These are actual questions asked by physicians at risk management seminars. The answers are general guidelines only and are not intended to be a comprehensive treatment of very complex subjects.)

"We have a computerized appointment system that we back up regularly. How long must we keep the actual papers that the system produces?"

Answer:
As long as you have ready access to the data, you needn't keep the paper documents past the statute of limitations for your state. However, be sure you can put your hands on the information if necessary.


"How late is "too late" to make a late entry in the medical record?"

Answer:
There's no hard rule except the rule of reason. Never make a late entry if there's been an adverse event and your late entry would clarify something that preceded that event. Doing so would make you look defensive. Never make a late entry on a chart that has already been copied and given to someone else. Never make a late entry if your credibility would be jeopardized (it's difficult to remember clearly things that happened several days or weeks ago).

Ideally a late entry should never be necessary. However, if you must make one, be sure you place it at the end of the current record (not inserted into the "proper" chronological sequence), make sure you reference the event to be clarified, and make sure you date the entry on the date you make it, properly identifying it as a late entry.


"I was transporting some records from my office to a satellite office; had a wreck; and several records were destroyed. I think I can reconstruct what's missing, but wouldn't that constitute an illegal or unethical alteration of the record?"

Answer:
Probably not, if you do it correctly. First, don't rely exclusively on your independent recollection of the patient's treatment. Solicit and acquire copies of lab reports, radiology reports, consultants' reports, records of previous treaters, etc. Use this information as the basis for the regenerated record. Preface the record with a prominent notation that the original record was destroyed in an accident, and that the current record has been reconstructed from your memory and from other data. That way, you're showing that you have made reasonable attempts to get accurate information, and you're not trying to hide or alter anything that was documented previously. Note: Some states have laws that address situations like this. Consult an attorney to find out what laws apply to you.

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