Q: As an MD, do each of my patient visits need to have a medical record?
I am a solo-practitioner that does not accept any insurance.
A:
Pursuant to Code of Medical Ethics- Medical records serve important patient interests for present health care and future needs, as well as insurance, employment, and other purposes.
This obligation encompasses not only managing the records of current patients, but also retaining old records against possible future need, and providing copies or transferring records to a third party as requested by the patient or the patient’s authorized representative when the physician leaves a practice, sells his or her practice, retires, or dies.
Why wouldn't you create a medical record of each patient visit? Even if you are a concierge clinic charging an annual fee, and not per each visit. Wouldn't you want a record of the visit? How else do you record vital signs, diagnoses, medications, treatment plans, progress notes, problems expressed by patient during the visit? There are so many issues if you do not maintain a proper and thorough medical record.
Tim Akpinar agrees with this answer
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