USA legal recordkeeping - Reply summary
Ted A. Trower
Description
Collection
Title:
USA legal recordkeeping - Reply summary
Creator:
Ted A. Trower
Date:
2/14/2000
Text:
My original question was:
I have been keeping two sets of records for my clients since I opened my
practice eight years ago. The first chart contains all clinical records.
The second chart contains all financial records. For convenience the second
(financial) chart usually contains copies of all prescriptions and insurance
information.
I have kept these two records separate under the belief that this was the
proper way to avoid unnecessarily releasing financial information were a
chart to ever be required in a legal proceeding. My new office manager has
pointed out that much of our problem with storage space for records could be
resolved if these two separate records were to be merged into a single chart.
How do other offices handle this issue? Does anyone else keep separate
records? Does anyone have experience with a legal situation where such
separation of data was, or would have been, helpful?
Thanks in advance for all responses. Given that this is a business problem
and not a clinical one I will remove all names from the summary of
responses. Obviously I will also honor any request that a response not be
re-posted in the summary.
----------------------------------------------------------------------------
----------------------
Replies follow:
----------------------------------------------------------------------------
----------------------
I doubt that the double chart system will shield you against releasing all
requested information in your office during a legal proceeding. Check with
your attorney about this. If this is true, then you can keep financial
information on one side of your chart and clinical on the other. I'd be
happy to forward a sample of our chart for your purview, should you request.
It's not fancy, but it seems to work.
----------------------------------------------------------------------------
----------------------
I think if you did not turn over both sets of charts you would be in an
extremely poor position. Although we do not charge for our services I have
been talking to our Director of Medical records about a similar problem and
ALL patients' records need to be in the same location. If a lawsuit came up
I think you would be in a serious world of hurt if you did not turn over ALL
the records.
----------------------------------------------------------------------------
----------------------
Your beliefs are good. Your new secretary is correct that the two charts can
be combined into one. It is usually best if the information if separated in
the chart - we use the Jeter system, financial on the right side, patient
info on the left. The chart has those metal bendable pieces to hold the
paperwork secure even if you occasionally drop a file.
It has worked well for a number of years.
If someone asks for patient care info, my staff just copies the left side of
the chart.
If Medicare wants billing info, we just copy pertinent info on the right
side.
----------------------------------------------------------------------------
----------------------
Ted, this is a false belief as a discovery request would be for ALL the
documents related to the individual. It would be illegal to withhold the
financial information. Collateral information such as component purchase
documents, instruction sheets, warranty, and, etc., would also have to be
produced, and the list goes on.
Keep only the records you really need to keep and work with your attorney on
a timely record destruction program.
----------------------------------------------------------------------------
----------------------
I just went through the same situation. We were maintaining separate charts,
one with clinical records and one for accounting purposes. We recently
combined the charts because of duplicate records needed in both, the extra
storage area required and the ever increasing costs associated with chart
development and retention.
We now separate the clinical and administrative records, in the same chart,
with the clinicals on the right and the administrative on the left. When we
see an individual who has two charts, we combine them with our current system
and shred the multiple duplicate records.
----------------------------------------------------------------------------
----------------------
While the opinion I am about to give is not a legal
opinion, it is based on my observations and
investigations regarding the format of the clinical
record for accreditation purposes.
By keeping clinical and financial records separate
we mean: do not record financial notes in the clinical
portion of the record, or the progress notes, as some
call them. I have often seen practitioners note
insurance, pricing, no charge and other financial
types of notes in the clinical narrative. This is not
appropriate. While not Illegal, it is the opinion of
legal counsel that such notes might persuade a jury
that you were more concerned with payment than with
treatment.
A common record system, in use today, separates the
clinical content, placing narrative, prescription,
technical/fabrication notes and other documents of a
clinical nature on one side of the chart (use a two
hole binder at the top of each side of the folder) and
then includes all billing, insurance, payment and a
separate chart page for writing notes regarding
financial issues, on the other side of the folder. If
staff have a place to note financial items, e.g. call
s to insurance, from client, etc, then they will not
have to record such information in the clinical
narrative.
If your records are subpoenaed, you will, in all
likelihood, have to yield the financial records, as
well. The point is to make sure that financial
information is maintained in a proper manner and not
mixed in with the clinical record. Having both
elements within the same folder is perfectly
acceptable.
----------------------------------------------------------------------------
----------------------
Our office has been keeping all records clinical and financial, as well as phone
call discussions all in one folder. As for storage of records I think they need
to be kept 8 years? So many get tossed out. Some folders are thick because the
person has been seen for many years. Their folder is obviously kept close at
hand.
----------------------------------------------------------------------------
----------------------
I only have one record for my patients, however when I receive a subpoena
for records they usually indicate specifically which records they feel
entitled to and then I make copies of the specifically requested records. I
also will refuse to accept a subpoena as being to vague, and request
clarification.
----------------------------------------------------------------------------
----------------------
We attended an Otto Bock Seminar
last Spring and listened to a gentleman from another facility tell a
horrifying Medicare audit story. Apparently Mcare was conducting an audit
with them and called their facility out of the blue saying, You have 2
minutes to fax the following files. For each 30 second interval after this
2 minutes, you will be fined $500. We were all listening in horror as I
think everyone is at least guilty of bad record keeping to some degree!
Splitting the files into a financial only folder would satisfy this
request. And give you more than 2 minutes to make sure the other file was
in good order. :)
----------------------------------------------------------------------------
----------------------
We keep one chart for both, but one side of chart is clinical the other is
financial. When we get requests for copies for legal proceedings we only
copy the clinical side.
In 14 years we have only once been asked for financial side only because
they wanted to project costs for future devices for that client. In that
case we gave them a separate projection geared for that client with approx
cost of increases, etc.
----------------------------------------------------------------------------
----------------------
Our patient file's have metal fasteners at the top. I keep all
prescription, progress records on the left. All signature's, legal
documents, etc., are on the right.
----------------------------------------------------------------------------
----------------------
Yours is the best way, but too cumbersome. I keep my files with the left
side the chart notes and the right side, everything else. This is legal.
You should not make financial notes on the patient chart notes. I do expert
witness work and know that my way is legal. Hope this helps. It will sure
make your storage problem better, but you will also increase the problem of
finding your charts. You will have to be very well organized to have your
files in the correct place and easy for everyone to find.
----------------------------------------------------------------------------
----------------------
We keep both sets of records in one file. The left side is for financial
data including any financial notes the administrators need to make as they
pursue reimbursements; dates and names and cryptic conversations they have
had with various insurance administrators, etc.. The right side is for all
things clinical. We usually ask what is desired when we are asked for
records.
----------------------------------------------------------------------------
----------------------
Clearly the two sided chart is a common solution to this problem. Thanks to
all who responded.
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, MI, USA
I have been keeping two sets of records for my clients since I opened my
practice eight years ago. The first chart contains all clinical records.
The second chart contains all financial records. For convenience the second
(financial) chart usually contains copies of all prescriptions and insurance
information.
I have kept these two records separate under the belief that this was the
proper way to avoid unnecessarily releasing financial information were a
chart to ever be required in a legal proceeding. My new office manager has
pointed out that much of our problem with storage space for records could be
resolved if these two separate records were to be merged into a single chart.
How do other offices handle this issue? Does anyone else keep separate
records? Does anyone have experience with a legal situation where such
separation of data was, or would have been, helpful?
Thanks in advance for all responses. Given that this is a business problem
and not a clinical one I will remove all names from the summary of
responses. Obviously I will also honor any request that a response not be
re-posted in the summary.
----------------------------------------------------------------------------
----------------------
Replies follow:
----------------------------------------------------------------------------
----------------------
I doubt that the double chart system will shield you against releasing all
requested information in your office during a legal proceeding. Check with
your attorney about this. If this is true, then you can keep financial
information on one side of your chart and clinical on the other. I'd be
happy to forward a sample of our chart for your purview, should you request.
It's not fancy, but it seems to work.
----------------------------------------------------------------------------
----------------------
I think if you did not turn over both sets of charts you would be in an
extremely poor position. Although we do not charge for our services I have
been talking to our Director of Medical records about a similar problem and
ALL patients' records need to be in the same location. If a lawsuit came up
I think you would be in a serious world of hurt if you did not turn over ALL
the records.
----------------------------------------------------------------------------
----------------------
Your beliefs are good. Your new secretary is correct that the two charts can
be combined into one. It is usually best if the information if separated in
the chart - we use the Jeter system, financial on the right side, patient
info on the left. The chart has those metal bendable pieces to hold the
paperwork secure even if you occasionally drop a file.
It has worked well for a number of years.
If someone asks for patient care info, my staff just copies the left side of
the chart.
If Medicare wants billing info, we just copy pertinent info on the right
side.
----------------------------------------------------------------------------
----------------------
Ted, this is a false belief as a discovery request would be for ALL the
documents related to the individual. It would be illegal to withhold the
financial information. Collateral information such as component purchase
documents, instruction sheets, warranty, and, etc., would also have to be
produced, and the list goes on.
Keep only the records you really need to keep and work with your attorney on
a timely record destruction program.
----------------------------------------------------------------------------
----------------------
I just went through the same situation. We were maintaining separate charts,
one with clinical records and one for accounting purposes. We recently
combined the charts because of duplicate records needed in both, the extra
storage area required and the ever increasing costs associated with chart
development and retention.
We now separate the clinical and administrative records, in the same chart,
with the clinicals on the right and the administrative on the left. When we
see an individual who has two charts, we combine them with our current system
and shred the multiple duplicate records.
----------------------------------------------------------------------------
----------------------
While the opinion I am about to give is not a legal
opinion, it is based on my observations and
investigations regarding the format of the clinical
record for accreditation purposes.
By keeping clinical and financial records separate
we mean: do not record financial notes in the clinical
portion of the record, or the progress notes, as some
call them. I have often seen practitioners note
insurance, pricing, no charge and other financial
types of notes in the clinical narrative. This is not
appropriate. While not Illegal, it is the opinion of
legal counsel that such notes might persuade a jury
that you were more concerned with payment than with
treatment.
A common record system, in use today, separates the
clinical content, placing narrative, prescription,
technical/fabrication notes and other documents of a
clinical nature on one side of the chart (use a two
hole binder at the top of each side of the folder) and
then includes all billing, insurance, payment and a
separate chart page for writing notes regarding
financial issues, on the other side of the folder. If
staff have a place to note financial items, e.g. call
s to insurance, from client, etc, then they will not
have to record such information in the clinical
narrative.
If your records are subpoenaed, you will, in all
likelihood, have to yield the financial records, as
well. The point is to make sure that financial
information is maintained in a proper manner and not
mixed in with the clinical record. Having both
elements within the same folder is perfectly
acceptable.
----------------------------------------------------------------------------
----------------------
Our office has been keeping all records clinical and financial, as well as phone
call discussions all in one folder. As for storage of records I think they need
to be kept 8 years? So many get tossed out. Some folders are thick because the
person has been seen for many years. Their folder is obviously kept close at
hand.
----------------------------------------------------------------------------
----------------------
I only have one record for my patients, however when I receive a subpoena
for records they usually indicate specifically which records they feel
entitled to and then I make copies of the specifically requested records. I
also will refuse to accept a subpoena as being to vague, and request
clarification.
----------------------------------------------------------------------------
----------------------
We attended an Otto Bock Seminar
last Spring and listened to a gentleman from another facility tell a
horrifying Medicare audit story. Apparently Mcare was conducting an audit
with them and called their facility out of the blue saying, You have 2
minutes to fax the following files. For each 30 second interval after this
2 minutes, you will be fined $500. We were all listening in horror as I
think everyone is at least guilty of bad record keeping to some degree!
Splitting the files into a financial only folder would satisfy this
request. And give you more than 2 minutes to make sure the other file was
in good order. :)
----------------------------------------------------------------------------
----------------------
We keep one chart for both, but one side of chart is clinical the other is
financial. When we get requests for copies for legal proceedings we only
copy the clinical side.
In 14 years we have only once been asked for financial side only because
they wanted to project costs for future devices for that client. In that
case we gave them a separate projection geared for that client with approx
cost of increases, etc.
----------------------------------------------------------------------------
----------------------
Our patient file's have metal fasteners at the top. I keep all
prescription, progress records on the left. All signature's, legal
documents, etc., are on the right.
----------------------------------------------------------------------------
----------------------
Yours is the best way, but too cumbersome. I keep my files with the left
side the chart notes and the right side, everything else. This is legal.
You should not make financial notes on the patient chart notes. I do expert
witness work and know that my way is legal. Hope this helps. It will sure
make your storage problem better, but you will also increase the problem of
finding your charts. You will have to be very well organized to have your
files in the correct place and easy for everyone to find.
----------------------------------------------------------------------------
----------------------
We keep both sets of records in one file. The left side is for financial
data including any financial notes the administrators need to make as they
pursue reimbursements; dates and names and cryptic conversations they have
had with various insurance administrators, etc.. The right side is for all
things clinical. We usually ask what is desired when we are asked for
records.
----------------------------------------------------------------------------
----------------------
Clearly the two sided chart is a common solution to this problem. Thanks to
all who responded.
Ted A. Trower C.P.O.
A-S-C Orthotics & Prosthetics
Jackson, MI, USA
Citation
Ted A. Trower, “USA legal recordkeeping - Reply summary,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/213766.
