Maintaining medical records is one of the most important functions of a modern medical practice. Properly maintained records ensure smooth operations of the practice and significantly decrease malpractice liability or probability of a misconduct accusation. This article discusses various issues related to proper medical record maintenance by New York healthcare practitioners and potential consequences of failure to do so.
New York Education Law 6530(32) requires that all New York practicing physicians and other healthcare professionals maintain detailed records for each and single patient. Maintaining proper medical records is a professional responsibility of a New York doctor or another practitioner. Very basically, each patient's record must accurately reflect the evaluation and treatment of the patient. There are two types of information that a medical record may contain. First, it is the actual patient information. Second, it is additional information that could not be released with the rest of the medical record. That includes some types of the physician's personal notes and observations, information confidentially disclosed to the physician on condition that it would not be disclosed to anyone including the patient, information that relates to prior treatments by another practitioner if the patient is able to request this information from the other physician, and certain information subject to NY Mental Hygiene Law that relates to some types of mental health treatments. Maintenance and disclosure of New York Psychiatric medical records is separately controlled by the New York Mental Health Law section 33. New York Medicaid providers and hospitals are additionally subject to specific requirements of medical record keeping which are quite extensive.
New York demands that medical records be maintained for at least six years and in some cases even longer.
Failure to maintain adequate medical records opens the door to a variety of consequences including refusal of an insurance carrier to defend malpractice claims, professional misconduct investigation and discipline, and criminal prosecution. A practitioner who has failed to maintain medical records properly and who submits insurance claims may be charged with insurance fraud and other crimes and violations. Insurance fraud may occur in many ways, but it is mostly defined by submitting false claims, billing for services not performed or for performing unnecessary treatment. Poorly maintained medical record that does not account for the evaluation and treatment of the patient or absent record is the red flag that would suggest some wrongdoing and trigger further investigation into the medical practice. Obviously, insurance fraud is a criminal act as well as professional misconduct.
Under New York law, any New York health care professional found guilty of violating the medical record maintenance and disclosure rules may be fined up to $2,000 per each violation. If such violation is "willful", the practitioner may be found guilty of a misdemeanor, which is a separate professional misconduct in its own right. There are numerous instances of professional discipline taken against New York healthcare practitioners' licenses for "failure to maintain accurate medical records" and fraudulent activities associated with it.
One way to prevent medical record related problems in New York is to consult an experienced New York medical or professional license defense or health law attorney or visit one of the seminars given by insurance carriers. Any medical practice should implement permanent record keeping and release procedures.
