Concerns regarding timely documentation of the medical record

Q. We have received several calls lately regarding the failure of providers to timely complete medical records and close out charts.  It appears that this is occurring primarily in the practice setting.  A physician contacted us with concerns about several colleagues (partners) who are leaving charts open for days, and in some cases weeks.  The physician indicated that this conduct is ongoing and was occurring even prior to COVID.  The physician is concerned about the potential exposure to liability.  The insured is seeking guidance relative to remedying this situation.

A. Timely documentation of the medical record is one of the most crucial weapons in prevention and defense of medical malpractice claims and litigation.  The medical record is considered legal evidence and must be accurate, complete, specific, and unaltered.   Documentation of a medical visit should occur simultaneously or shortly thereafter but providers should be mindful that any substantive documentation occurring after 48-72 hours of the visit will be likely be inaccurate.

Failure to maintain timely and complete medical records could have severe licensing and credentialing consequences. In a recent (out-of-state) case, a physician’s hospital privileges were suspended for 45 days for repeatedly (despite numerous warning) failing to timely document medical records. The physician was surprised to learn that the suspension triggered a reporting requirement with the National Practitioners Data Bank.

The medical record also plays an important role in justification of reimbursement claims made to patients’ insurers and an incomplete and untimely medical record leaves a medical provider extremely vulnerable to claims of fraud.

Medical practices and organizations must develop communication strategies to deal with untimely documentation of medical records and have consequences for those who violate policy.

IMPORTANT – The 21st Century Cures Act information blocking requirements now grants patients real-time access to their medical records, including consultation notes, discharge summary notes, history and physical notes, imaging narratives, laboratory report narratives, pathology report narratives, procedure notes, and progress notes.  These records are now available instantly and timely documentation is an absolute necessity moving forward.