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.
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
Justia Ask a Lawyer is a forum for consumers to get answers to basic legal questions. Any information sent through Justia Ask a Lawyer is not secure and is done so on a non-confidential basis only.
The use of this website to ask questions or receive answers does not create an attorney–client relationship between you and Justia, or between you and any attorney who receives your information or responds to your questions, nor is it intended to create such a relationship. Additionally, no responses on this forum constitute legal advice, which must be tailored to the specific circumstances of each case. You should not act upon information provided in Justia Ask a Lawyer without seeking professional counsel from an attorney admitted or authorized to practice in your jurisdiction. Justia assumes no responsibility to any person who relies on information contained on or received through this site and disclaims all liability in respect to such information.
Justia cannot guarantee that the information on this website (including any legal information provided by an attorney through this service) is accurate, complete, or up-to-date. While we intend to make every attempt to keep the information on this site current, the owners of and contributors to this site make no claims, promises or guarantees about the accuracy, completeness or adequacy of the information contained in or linked to from this site.