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Dimitry K., Esq.
Dimitry K., Esq., Attorney
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Experience:  Run my own successful business/contract law practice.
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Hello Mr. Kaplun, I need a Texas statute regarding recreating

Customer Question

Hello Mr. Kaplun,
I need a Texas statute regarding recreating a patient's medical record. For instance, if a practitioner is charting on a patient at the bedside and the wrong information is charted or ink pools and the document is illegible so a new document is created and the old one is properly disposed of. There are no multiple entries. It's a single page document like a progress note or an OR record. It's not a prior entry. It's done immediately before completing the original record.
Submitted: 3 years ago.
Category: Business Law
Expert:  Dimitry K., Esq. replied 3 years ago.
Thank you for your question and thank you for requesting me specifically.

I have been reviewing the Texas Administrative Code (T.A.C.) for you, and I do not see anything directly on point that pertains to recreating the record. In Texas, medical records maintenance, upkeep, charges, and disposal are governed under Title 22, Part 9, Chapter 165 of the T.A.C. The only comment about the state of the records that Texas requires are that they are "legible" but does not somehow control the process of copying besides making sure that the original is disposed off confidentially.

Here is the law below:

http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=T&app=9&p_dir=P&p_rloc=107789&p_tloc=&p_ploc=1&pg=16&p_tac=&ti=22&pt=9&ch=165&rl=2

Good luck.

Edited by Dimitry Alexander Kaplun on 2/2/2011 at 3:52 AM EST
Customer: replied 3 years ago.
Is it illegal to destroy the first document? I have been reprimanded for this, however it is a common practice. Like if a physician writes on a progress note and realizes he wrote all the wrong labs. He can tear out the sheet and rewrite it provided there are no other entries on the sheet and it was not a prior entry (haven't come back to it an hour later).
Expert:  Dimitry K., Esq. replied 3 years ago.
Thank you for your follow-up.

The law only permits the Physician to destroy the record if it relates to a civil, criminal, or administrative proceeding and the physician is aware of resolution of the case (22.9.165.1(b)(3)), or if document is 7 years or older ((b)(1)). All other documents must be preserved. So yes, it is not legal to destroy such a document. While it may be common practice it is not under the guidelines of state law.

Good luck.




Sincerely, XXXXX XXX.


_____________________________________________________________________
Please click "accept" so I can be compensated for my assistance. Thank you!
Customer: replied 3 years ago.

Uggh! I think I made a fool of myself.

I referenced this article:

Making Changes in Charts Do's and Don'ts of Documentation

By Joan Roedigerand and Patricia Salmon,

Obermayer Rebmann Maxwell & Hippel LLP

February 1, 2005, Physician's Practice, Vol. 15, No.3

www.physycianspractice.com/display/article/1462168/159055

 

The fact that a record may contain something that is incorrect or that may have legal implications does not justify destroying, rewriting, or replacing the prior record. Doing so places the credibility of the entire record in jeopardy.

The only time it is appropriate to destroy and rewrite a medical record entry is when an error is recognized when it is being written and before the entry has been completed. For instance, if you are in the middle of a patient exam and you realize you wrote the wrong name on the progress note, you can properly dispose of the incorrect progress note and start over.

Expert:  Dimitry K., Esq. replied 3 years ago.
Thank you for your follow-up.

Exactly right--once it becomes "record", it can no longer be destroyed other than what both state and federal law permit as reasons for removal. Anything else is illegal and can ultimately cost you your job, not to mention possible charges for tampering with a patient's record.

Good luck.

Edited by Dimitry Alexander Kaplun on 2/2/2011 at 4:35 AM EST
Dimitry K., Esq., Attorney
Category: Business Law
Satisfied Customers: 35654
Experience: Run my own successful business/contract law practice.
Dimitry K., Esq. and 10 other Business Law Specialists are ready to help you
Customer: replied 3 years ago.
Thanks Mr. Kaplun!
Expert:  Dimitry K., Esq. replied 3 years ago.
Anytime, happy to have helped!

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