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Can a Physician be Disciplined for Inadequate Medical Records?

June 5, 2014
Est read time: 2 minutes


Generally speaking the answer is yes.


I.  What's the purpose of medical records?

Medical records are maintained for the following purposes:

-To serve as a basis for planning patient care and for continuity in the evaluation of the patient's condition and treatment.

-To furnish documentary evidence of the course of the patient's medical evaluation, treatment, and change in condition.

-To document communication between the practitioner responsible for the patient and any other health care professional who contributes to the patient's care.

-To assist in protecting the legal interest of the patient, the hospital, and practitioner respone sible for treatmentl

For more specific provisions relating to the standards for adequacy of medical records consult Rule 64B8-9.003, Florida Administrative Code (F.A.C.) which can be found at OF PRACTICE FOR MEDICAL DOCTORS&ID=64B8-9.003



II.    What kind penalties can a physician face in Florida for inadequate medical records?

The Florida Board of Medicine regulates the licenses of physicians in the State of Florida.  Allegations that a physician failed to keep appropriate written medical records, if proven, can result in sanctions to the physician's license ranging from "reprimand" to "two (2) year suspension followed by probation, and an administrative fine from $ 1,000.00 to $ 10,000.00."   If a second violation occurs the fines can go as high as $5,000.00 too $ 10,000.00 per violation.  See Rule 64B8-8.001(2)(m), Florida Administrative Code (F.A.C.).


III.   What steps can be taken to prevent violations of medical records laws?

Some physicians have found hiring a medical records consultant or privacy officer beneficial to their overall risk management program.  Consultants who have experience in health information management may be helpful.  However, such advisors usually do not have in-depth legal knowledge to advise on all facets of medical records law, from adequacy of the records themselves to HIPAA and protected health information issues.   A review by an experienced health care attorney may also be of benefit.


If you have questions about medical records law or have received a citation or administrative complaint from the State of Florida alleging violations of law I may be able to assist you.  An experienced health care attorney is familiar with this area of law.  For a free no  obligation consultation call Howell, Buchan & Strong, Attorneys at Law at 850-877-7776 to set up a telephone appointment.

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Contact the law firm of Howell, Buchan & Strong at 850-877-7776 to set up a FREE no-obligation consultation. Our firm represents physicians, nurses, psychologists, and other licensed professionals statewide.
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