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physician failed to document the rationale for the care of a patient, ELECTRONIC
according to a TMB news release. The other physician inade- MEDICAL RECORDS
quately documented conversations with a patient pertaining to the
rationale for surgery. If a physician has been issued a prior order Medical Records Q&A
by TMB for inadequate recordkeeping, he or she may be required
to take a Physician Assessment and Clinical Education course in The TMA Knowledge Center receives many
recordkeeping. questions regarding medical records.
Here are the top five:
The board issues administrative penalties at its discretion, how-
ever, and can go north of the $2,000 penalty. For example, last Q: How much can we charge to supply copies of
April, the board issued a $3,000 penalty to a physician who ad- records? Are the fees different for records supplied in
mitted failing to adequately document medical records for approx- electronic format?
imately 11 visits and to “making late entries without indicating
the amendments were not made contemporaneously with original A: Per Texas Medical Board rules, physicians may
notations,” TMB said in a news release. charge up to $25 for the first 20 pages of a paper record
and 50 cents per page for every copy thereafter. For
Ms. Robinson says the board’s enforcement activity is com- copies of an electronic record, doctors may charge up to
plaint-based in the majority of cases. It only has the authority to $25 for 500 or fewer pages, or $50 for more than 500
initiate inspections without a complaint in cases involving office- pages. However, simply charging the maximum amount
based anesthesia and pain management. TMB can file a complaint, permitted under the rules is not sufficient unless such a
Ms. Robinson says, “but that generally only happens when we re- charge is “reasonable” and “cost-based.”
ceive information through our offices another way,” such as if the
board performs a CME audit and finds a physician doesn’t have Q: Can we forward copies of records we have re-
the proper credits or if a physician has been found guilty of a crime. ceived from other physicians?
Depending on the final resolution of a case, the board may also A: Yes. In fact, you are required to do so when some-
be required to report a violation to the federal National Practitioner one requests medical records. The Medical Practice Act
Data Bank, which has its own guidelines about what certain enti- requires physicians responding to a request for records
ties need to report. to provide “records received from a physician or other
health care provider involved in the care or treatment
“So it could be that there was a small error, and the board feels of the patient.” The Medical Practice Act contains no
that the appropriate resolution is a remedial plan, which is a exception for documents stamped “Do Not Copy or
nondisciplinary order that is not reportable to the National Prac- Forward” or “Not for Re-Release.”
titioner Data Bank,” Ms. Robinson said. “However, there could
be a really, really large and egregious set and pattern of violations. Q: Can we release medical records of deceased pa-
So depending on the penalty there, if a disciplinary action is taken, tients to their family members?
it is absolutely reportable to the National Practitioner Data Bank.
So anything connected with the practice of medicine that’s a dis- A: A family member must be a “personal representa-
ciplinary action in the vast majority of cases is federally mandated tive” of the deceased to consent to the release of the
to be reported.” medical records. A “personal representative” is someone
who has the authority to perform transactions on behalf
Ms. Robinson says TMB does not keep statistics on how many of the deceased’s estate.
remedial plans it issues for medical record violations. For more in-
formation on remedial plans and TMB’s enforcement process, visit Q: Can we withhold supplying copies of medical
www.tmb.state.tx.us/page/enforcement. records because of a past-due balance for services?
Joey Berlin can be reached by phone at (800) 880-1300, ext. A: No. A physician may generally retain records until
1393, or (512) 370-1393; by fax at (512) 370-1629; or by email. payment of a copy fee is made but may not withhold
copies of the records because of a past-due balance for
For more information on medical records, see white papers and in- treatment.
formational articles from TMA’s Office of the General Counsel. If you
have questions about medical records, contact the TMA Knowledge Q: Do I need patient authorization to forward med-
Center by calling (800) 880-7955 or by email. ical records to another physician for treatment pur-
poses?
A: No. HIPAA permits doctors to disclose patient
health information to other doctors for treatment pur-
poses without patient authorization.
visit us at www.bcms.org 17
