Documenting the Provision of Services
Law, rules and regulations, not Guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to this Guideline may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations, some citations of which are listed at the end of this Guideline.
- You should maintain written records related to all substantive
contact with patients, which may include:
- Reason for initial contact, preliminary assessment, and subsequent disposition.
- Comprehensive evaluation of problems, including the interpretation of tests and measurements, to determine treatment and establish the diagnosis and prognosis.
- Initial plan for service, including specific goals and the interventions related to each goal. If actions are delegated to another licensed professional, specify those tasks and how the patient"s progress will be assessed or reviewed.
- Dates of service and treatment performed during each contact with patient, including specific actions or follow-up to be taken by the patient or podiatrist, if relevant.
- Discharge summary, including specific notation of any plans for future treatment and/or referral or circumstances under which a patient stops using services against your advice or because you are closing the practice.
- Any consultations with other professionals, including reason for consult and outcome, and patient"s authorization to release information.
- You should maintain all paper and electronic patient records in a secure area accessible only to authorized persons and in a manner that lends itself to substantiating the records to be trustworthy and unalterable.
- Be aware of retention requirements for patient records, including the period of time you are required to retain records by law. Also, you should develop a plan to retain longer when appropriate and establish requirements for providing patient access to records. All patient records must be retained for at least 6 years. Records of minor patients must be retained for at least 6 years and until one year after the minor patient reaches the age of 21 years.
- Be familiar with laws regarding patient access to records and restrictions on fees charged for copying, methods to address disputed issues, and other relevant matters.
Citations of Pertinent Law, Rules or Regulations: