The texas medical board can reprimand doctors for poor documentation

In Fiscal Year 2017 the Texas Medical Board (TMB) received 8,114 complaints against medical professionals by patients, patients’ family members, health care professionals, and other sources. The TMB reviews every complaint it receives to determine if it has jurisdiction over the matter, and if so, conducts a preliminary evaluation to determine if there is sufficient evidence to support the allegations.
The TMB has the authority to take disciplinary action against its licensees for any violation of the Medical Practices Act or Board rule.
Texas doctors should be aware that if the Board has concerns about the medical care given, even if the evidence born of the investigation is not clear cut, the Board may reprimand the doctor in question for poor documentation.
TMB rule violations regarding medical records are not uncommon. The Rule on the Contents of Medical Records states: “Regardless of the medium utilized, each licensed physician of the board shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible.” 22 Tex. Admin. Code §165.1.
For the purposes of §165.1, an “adequate medical record” should meet the following standards:

  • The documentation of each patient encounter should include:
    • Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
    • An assessment, clinical impression, or diagnosis;
    • Plan for care (including discharge plan if appropriate); and
    • The date and legible identity of the observer.
  • Past and present diagnoses should be accessible to the treating and/or consulting physician.
  • The rationale for and results of diagnostic and other ancillary services should be included in the medical record.
  • The patient’s progress, including response to treatment, change in diagnosis, and patient’s non-compliance should be documented.
  • Relevant risk factors should be identified.
  • The written plan for care should include when appropriate:
    • Treatments and medications (prescriptions and samples) specifying amount, frequency, number of refills, and dosage;
    • Any referrals and consultations;
    • Patient/family education; and,
    • Specific instructions for follow up.

The foregoing list of standards an adequate medical record must meet is not exhaustive. You can review the full list here.
The TMB Rules regarding the contents and maintenance of medical records are extensive. A single violation of these rules can put your medical license in jeopardy. If you are facing a complaint and investigation by the TMB, you should not go it alone. It is critical that you consult with an experienced Texas medical license defense attorney. There is far too much on the line when the medical care you provided is being questioned.
Hire the Experienced Medical License Defense Attorneys of BERTOLINO LLP
If you have been notified of a complaint filed against you with the Texas Medical Board, BERTOLINO LLP can help. We are experienced medical license defense attorneys and we know how to navigate the TMB’s complaint process. We are prepared to represent you at any legal hearing or proceeding regarding your professional license, including:

  • Temporary Suspension Hearings
  • Informal Settlement Conferences (ISC)
  • Show Compliance Proceedings
  • State Office of Administrative Hearings (SOAH) Proceedings

BERTOLINO LLP represents licensed professionals across the entire State of Texas. If you are facing disciplinary action from a professional licensing board, contact us today or call (512) 476-5757 and schedule a case evaluation.

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