Maintaining Medical Records In New York And Professional Misconduct Of Physicians

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