General Questions

We’ve compiled a list of answers to the most frequently asked questions from our members. They are designed to give you a better understanding of our organization, our services, and other technical information. 

Medical Records

What are the elements of an informed consent progress note?
  1. Mr/Mrs/Ms ________, a ___ year old male/ female, presents with a chief complaint of ______.
  2. The patient has a history of ______ (or the patient has no significant medical history).
  3. After examination and evaluation of the patient and the diagnostic tests, I concluded that the patient’s condition would benefit from _______.
  4. I discussed the medical and surgical alternatives, including ______, with the patient and/or family.
  5. I discussed the implications of non-treatment which could result in _____.
  6. I discussed the benefits of the procedure, including ______, and the risks of the procedure including ______, infection, loss of blood, nerve damage, and death with the patient and/or family.
  7. I discussed the post-operative and rehabilitative phase of the options, including _______.
  8. I discussed the possible outcomes of the treatment options, such as ________, with the patient and/or family.
  9. The patient and/or family have verbalized comprehension of our discussions.
  10. The patient and/or family asked questions regarding ______________ which were addressed.
  11. The patient and/or family and I agreed upon ______ as a treatment plan and will schedule surgery/(other procedure) _____ in the near future/on (date)/as soon as possible/etc.
How can I add a note to the medical record? How do I correct an error in charting?

Care must be taken to ensure the record is not altered, as altering a patient’s medical record is a criminal act in the State of Michigan. It also makes it virtually impossible for your attorney to defend your case in a malpractice suit.

A late entry that is dated and signed is permissible if it provided additional factual information and does not have the appearance of being overly defensive.

Do not erase, obliterate, or white out notes. When it is necessary to change or amend notes, place one line through the entry and write "error" over the entry with initials and a date. See your MPIE Physician Office Risk Management Manual for an expanded discussion.

What are the risks/issues when the physicians take medical records home or out of the office to complete dictation?

Removing medical records from the office is a risky practice!

This question always concerns me from a risk exposure standpoint for the physician. This concern is based on the follow items:

  • There is no medical malpractice insurance coverage under MPIE for fines related to breaches of patient confidentiality or inadvertent disclosure of protected health information under HIPAA.
  • Civil money penalties are based on each disclosure (that means each record that has a breach not the act of the breach alone). These penalties range from in excess of $25,000 to a min of $100 each if there are no damages (meaning the individual did not suffer as a result of another reading or obtaining their PHI) if there are damages than there is no cap on the penalties. There may be other sanctions that can be levied against the P.C. in addition to those against the individual physician for letting the records out of his/her personal control.
  • The patient can sue the physician directly for breach of physician/patient confidentiality. Thus the physician incurs the potential for civil damages in addition to any sanctions or fines levied by the Federal Government.

At times, there are situations when transport of an original medical record is necessary; such as a practice that has more than one location and allows patients to be seen at the either location. The original medical record will need to be available at the location where the patient is to be seen. In this situation, transport of original medical records is necessary and must be moved in a confidential and secure manner. Confidential and secure transport is considered to be in a locked metal case (to avoid fire or water damage in the event of an accident). Either a combination or key lock is acceptable; the practice manager should have a duplicate key or the combination to allow retrieval and replacement of the records back into the office.

While we at MPIE are glad that this is an infrequent question, the fact that it is asked at all does concern us. MPIE discourages the removal of medical records from the practice for the sole purpose of completing documentation and strongly recommend that anytime original medical records are taken from the office that they are transported in a confidential and secure manner.

How long should we keep medical records?

From a medical malpractice stand point the safest approach is to keep records indefinitely. If you cannot do this, the minimum time to retain records we recommend are:

Adult patient records: Retain records 10 years from the last date of treatment/visit.

Deceased patient records: Retain records for 5 years from the date of death.

Pediatric patient records: Retain these records until the minor reaches 25 years of age.

Obstetric patient’s prenatal records: Who encountered difficulties, keep these records for 21 years from the birth of the child (unless neurologically impaired, see below).

Neurologically impaired adult or infant: Retain indefinitely.

Indefinite retention is recommended for those records where an adverse outcome or patient dissatisfaction occurred.

Can I release a minor’s record to a non-custodial parent? What about stepparents?

Both biological parents have the right to their child’s medical record, regardless of custody, unless there is a court order barring the parent from obtaining a copy of the records. The office should retain a copy of any such court order in the child’s medical record. If there is suspicion that the child or custodial parent might be in danger as a result of the release, the release may be withheld until the safety of the custodial parent and child is verified or a court order preventing the release is provided to the office. Neither parent has the right without the minor’s consent to information protected by state statute such as care and treatment related to pregnancy, HIV, STD, substance abuse and mental health, please see state statues for specifics on age requirements and release specifications or contact the MPIE Risk Management Department.

Stepparents, unfortunately, have no rights to consent to treatment or release of information on their stepchildren, unless it is an emergency, in which case treatment is warranted. Only a biological parent, adoptive parent or a guardian appointed by the court can consent. An office may request that the biological parent(s) accompany the minor for the initial visit at which the biological parent may provide in writing their consent for their spouse/stepparent to consent to treatment and information release. It is recommended that the signature of the other biological parent also be obtained to avoid any allegations that the child was treated with out that biological parent’s consent. Verification of signatures and identification may be obtained by visualizing the driver’s licenses and obtaining a photocopy for the child’s record.

A mailing list I’m on advised “do not put a patient complaint in the patient record unless it is directly related to the patient’s medical condition.” The rationale was that once it is in the medical record, it could be subpoenaed and used in court. We currently dictate all patient comments (pro and con) into the medical record. Some may be about care given (hospital or office), bills, and insurance coverage, etc. Should we not be doing this?

In regards to the question of recording complaints in the medical record: it is a best practice and appropriate to record complaints if they are related to care and treatment in the medical record. The medical record is evidence and will be subpoenaed if there is an allegation of negligence (suit/claim) and used in court for both the defense and plaintiff—if there was a complaint in relation to care/treatment it will of course be directly related to the patient’s medical care—and thus should be in the chart.

It should be accompanied by a short note that states no more than that the patient was contacted (by phone, by mail) regarding this concern/complaint in order to investigate and respond. Remember, you do not want to place statements in the chart that indicate that you/your office staff contacted your medical malpractice insurance company or attorney regarding the complaint as these statements are not appropriate in the medical record as it does not pertain to the care and/or treatment of the patient, but rather is business related and inappropriate for the medical record.

Complaints regarding rude staff/environmental (office) issues/operations (wait times) while not related to medical care may become important at some point if you were required to show evidence of behavior that was disruptive or unacceptable (such as use of off color comments or threats)—if you terminated a patient for this type of behavior the chart should reflect a pattern of this abusive/unacceptable behavior and the physician’s steps to address the unacceptable behavior to substantiate the termination, if it was ever challenged.

Complaints about care received from other providers or at the hospital are important as they may be related to care and treatment the patient received. Always be factual and objective when you chart complaints of this nature. Always seek to chart complaints in quotations using as much of the patient’s exact words as possible. For example: Patient states “Dr. Smith didn't wear plastic gloves when I saw him, that's why I got this infection.”

Complaints about bills and your actions to investigate/resolve/respond back to the patient are important in light of fraud and abuse issues; again these types of complaints appear to not be appropriate for the medical record as they do not pertain to care and treatment but are more related to the business of the practice. If you have a billing system or separate filing system that could be utilized for billing complaints that should be done. Billing complaints and resolution/response are a must to record due to fraud and abuse investigations and potential sanctions—just not in the medical record.

My patient is deceased. I have received a record request from a family member, but obviously, my patient can no longer provide authorization. Who can?

Under Michigan law, the authority to release a patient’s records succeeds to one of two classes of persons upon the patient’s death. The first is the legal representative of the patient’s estate—generally designated as Executor, Guardian, Administrator, or Trustee. The second is a beneficiary (or heir) of the patient’s estate.

This second group includes next-of-kin and other persons designated as beneficiaries under a will/trust, made by the deceased patient. A surviving spouse normally would qualify as a beneficiary, as well as immediate family members. If there is doubt about who is requesting a copy of medical records, ask for proof. Generally, a photocopy of the deceased patient’s trust or will, and a copy of the requestor’s photo I.D. will suffice.

Practically speaking, physicians will know of a patient’s death and will know the surviving family member(s). However, if the physician has not heard before about the patient’s death, or has never met the purported family member, then requesting proof of both appears to be reasonable and prudent. Under state law, physicians are obligated to take reasonable measures to safeguard the confidentiality of medical records and to disclose protected medical information only to authorized recipients. Generally, death certificates and copies of the deceased patient’s trust or will are readily available. Asking the requesting party to provide them should not present any significant problems or cause undue delay.

An Authorization for Release of Medical Records should be signed by the legal representative or beneficiary on the patient’s signature line. The signer should print both name and status (e.g., Executor of the Estate, Beneficiary) next to his or her signature.