Public Health Law Map - Beta 5 - Medical and Public Health Law Site

disclose information about the patient or the defendant reasonably should have
anticipated that his actions would induce the physician to disclose such information;
and (3) the defendant did not reasonably believe that the physician could disclose
that information to the defendant without violating the duty of confidentiality that the
physician owed the patient.” [Alberts v. Devine, 479 N.E.2d 113, 121 (Mass. 1985).]
Such a standard raises questions about many consulting schemes designed to increase
billing by reviewing records and tuning up the billing.
B. Medical Office and Clinic Records
Most medical practices have changed dramatically in the last 10 years. Their patient
panels turn over rapidly, they no longer control referrals to specialists, and they are
treating sicker patients in the office because of the pressure to keep patients out of the
hospital. Malpractice risks have not changed in the last decade, but the risk of being
prosecuted for billing fraud has gone from negligible to significant. Yet, with all the
changes, many medical care practitioners keep patient medical records in a manner that
assumes that they know each patient personally and that the patient will be there
forever—records that would not look out of place in an office of 50 years ago.
The Joint Commission provides detailed requirements for the maintenance of medical
records in the hospital and in ambulatory care centers. There are no corresponding,
uniformly recognized standards for physician’s office records. Consequently, there is a
tremendous variation in the quality of physicians’ office records. Physicians should use
a standard medical record format such as the problem-oriented medical record for all
their medical records. Whereas the Joint Commission does not certify physician’s
offices, the standards for ambulatory care centers provide useful guidance for records
management in the physician’s office. [Standards for Ambulatory Care. Oak Brook,
IL: Joint Commission on Accreditation of Healthcare Organizations; 1998.]
1. Basic Patient Information
Although proper charting of medical and treatment information has always been
important for medical malpractice prevention, it is now also important as a
compliance measure for billing fraud issues. The old rule in medical malpractice was
that if it was not in the chart, it was not done. Auditors looking for insurance or
Medicare fraud use the same standard: if the medical necessity of the care is not
documented along with the care, then the bill for the care is fraudulent. In the best
case, the medical care practitioner will have to refund the amount paid. In the worst
case, there is a $5,000 fine per fraudulent bill, plus jail time.
The most important information is the basic patient data. The chart must contain
enough information for a medical care practitioner unfamiliar with the patient to
provide appropriate care. This should include physiological information, therapeutic
information, and any special patient characteristics such as allergies or handicaps.
This information should be summarized on a cover sheet. There are several
acceptable styles for providing this summary, but they share an emphasis on rapid
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