Kansas Healthcare Professionals – Maintaining Complete Medical Records

In today’s technological world, nearly every important document is now in electronic format.  People can “e-sign” documents now, eliminating the need to spend the time, energy and money into making paper copies of every document.  Many healthcare providers, such as physicians and hospitals, are transitioning from tangible, paper copies of medical records, to a completely electronic system that makes it easier for healthcare professionals and patients alike to access important medical information.  Along with the transition from hard or paper copy documentation to electronic documentation comes the added responsibility of ensuring that all medical records are complete and accurate.

How Can Kansas and Missouri Healthcare Professionals Get in Trouble?

As a healthcare professional, if you are not aware of the particular rules and regulations regarding how to maintain medical records, such as checking them for accuracy, you could be held responsible if important information is omitted from a patient’s record, whether intentionally or accidentally.  For example, if you are a nurse and it is your job to ensure a physician has a complete list of a patient’s medication, and you fail to check the accuracy of the medication list, that patient’s health could be at risk if he or she does not receive a prescribed medication.

Further, medical records don’t simply involve just a physician or nurse’s notes and/or recommendations for a patient.  For example, when patients undergo procedures that require the implantation of a particular device (such as a hip replacement), there is always a “product sticker” that is supposed to be placed or recorded in some fashion along with the patient’s operative report and related medical records. 

Oftentimes, hospital staff may forget to include this product sticker which essentially documents that a particular patient did in fact have a hip replacement.  This can be troublesome for many patients if they require specific documentation relating to their hip implant in the future.  While an operative report may clearly document that a procedure was performed, the medical record is not complete without documentation of what type, brand, and model of the device was implanted. 

We all make mistakes, and small errors in medical records are unlikely to result in disciplinary action or the revocation of your professional license unless the error caused some sort of substantial harm to the patient and/or other healthcare professionals.  However, what may seem like a small mistake (such as failing to document the type and brand of hip implant placed into a patient, as discussed above), could lead to a whirlwind of problems down the line.  The omission of this type of documentation may require the hospital or physician to complete an affidavit that shows what type of product was implanted during a hip replacement procedure.  An affidavit may be sufficient to cure any medical record inaccuracies, but it is always best to strive for having a complete medical record from the start.

The bottom line for Kansas and Missouri healthcare professionals today is that there is a strong push for ensuring that medical records are extremely thorough and complete.  The more complete a medical record is, the less likely healthcare professionals are to face potential disciplinary action and the loss of a hard-earned professional license.   

Contact the Sanger Law Office Today to Schedule Your Free Consultation

If you are a Kansas or Missouri licensed healthcare professional and you may be facing disciplinary action with the Kansas or Missouri Board of Healing Arts, and/or your license is at risk, it is imperative that you speak with a Kansas or Missouri professional license defense attorney right away.  A qualified Kansas Professional Licensing Attorney can help you keep your professional license and practice as a healthcare professional for years to come.  Attorney Danielle Sanger of the Sanger Law Office devotes her entire law practice to helping Kansas and Missouri professionals whose licenses are at risk.  As a former Assistant Attorney General of Kansas, Danielle Sanger knows what to expect from the Board of Healing Arts.  To schedule a free consultation with Danielle Sanger, call the Sanger Law Office today at (785) 979-4353.