Decent medical documentation indorses patients' and physicians' best interests for numerous reasons. Recording all relevant evidence of a patient's care helps practitioners screen occasions, and minimizes the risk of faults during the treatment process. Maintaining cautious responsiveness to detail also lessens the likelihood of patients returning for additional treatment. Particularly, the procedure also demands a high degree of self-evaluation, which is crucial to endorsing good clinical practices, as well as a practitioner's professional development. According to a November 2006 report by the Ontario Ministry of Health and Long-term Care, keeping appropriate records improves patients' clinical aftermaths once they leave the hospital. Approximately 20% of patients experience adversarial events after discharge, for instance, drug reactions, infections, and procedural complications. Majority of these problems result from delayed or inadequate information given to subsequent health care providers. For this reason, proper documentation is the best justification against a malpractice claim. Physicians ought to ensure that medical operations, for instance, X-rays and other lab work are executed diligently, and follow up with the patient enacted. Notably, this act decreases the risk of a missed diagnosis.
Florida Record Keeping and Documentation Requirements
In Florida, all medical health providers are obligated to sign and record all therapeutic admittances inside two business days from the actual time of provision. Precisely, this activity should be authenticated through signatures and written initials of the presiding physicians. According to Section 456.079, F.S., of the Florida medical laws, the Board provides within this rule disciplinary guideline which shall be imposed upon applicants or licensees whom it regulates under Chapter 458, F.S (“Florida Administrative Code and Florida Administrative Register”). The purpose of this regulation is to alert contenders and licensees of the ranges of consequences which would routinely be imposed unless the Board finds it essential to deviate from the procedures for the stated reasons given within this rule (Birkhead, Klompas, & Shah, 2015). According to the Floridan health legislation, ranges of penalties provided are based upon a single count violation of each provision listed, and multiple counts of the desecrated provisions or a combination of the violations may result in a higher penalty than that for a single, isolated violation (“Florida Administrative Code and Florida Administrative Register”). Characteristically, attempting to obtain an initial license through fraudulent means is equivalent to a fine of $10,000. Additionally, dentists who desire to renew their licenses through bribery are likely to face revocation of their licenses and a penalty of $10,000.
Maryland Record Keeping and Documentation Requirements
Health care institutions in Maryland are obligated to disclose medical records within a realistic time, but no more than 21 working days after the date a person in interest requests the disclosure. Besides, a health care provider that expressively and willfully refuses to disclose medical records in the desecration of Health-General Article § 4-309 (a) (d) is accountable for actual damages (“For Your Information: Medical Records"). Additionally, the fees that may be charged for planning and production of medical records may be adjusted yearly for inflation using the Consumer Price Index on July 1 of each year (“For Your Information: Medical Records”). Beginning January 1, 2014, adjusted rates for medicinal record copying are as follows: a preparation fee of no more than $22.88 plus a price of no more than 76 cents per page copied, plus the fixed cost of delivery and handling. Besides, reasonable fees may be charged for duplicate x-rays.
Penalties
Perpetrator found to be guilty of wrongdoing, and on conviction are subject to a fine not surpassing $1,000 for the first transgression, and not exceeding $5,000 for each subsequent conviction for the desecration of any endowment of this subtitle.
Georgia Record Keeping and Documentation Requirements
According to the Georgian Board of Dentistry regarding record keeping, the provider having protection and control of any evaluation, diagnosis, projection, laboratory report, or biopsy slide in a patient´s record shall retain such information for not less than ten years from the date such item was produced. Besides, a distinct provider who has superannuated from, or sold his or her professional practice should notify the patient of such developments (Gellert, Ramirez, & Webster, 2015). Also, the patient should be allowed to select a person of his/her own choice as the safe custodian of their medical information. A hospice which hosts a patient shall retain patient records per the stipulated rules and protocols for hospitals as issued by the department according to Code Section 31-7-2.
Penalties
Failure to retain patient records within the mandatory required period of ten years may automatically lead to the loss of a dentist’s operational license. Additionally, there is a high likelihood of a legal malpractice case against a practicing dentist, which may lead to severe fines.
Published Cases
Case One in Maryland
A woman from Montgomery County in Maryland filed a dental lawsuit. According to the complainant, a dentist deliberately left potentially harmful particles behind during a procedure. Resultantly, the specimen led to the contraction of an illness. The plaintiff summoned the defendant dentist regarding the inexplicable pain on the tooth, after which the specialist advises on a crown and a root canal (“Dental Malpractice Infection Lawsuit in Montgomery County.”). The tooth is ground down by the dentist, but the pain persists. The complainant seeks another dentist, who confirmed the existence of a particle left after the root canal procedure. After corrective surgery, the patient filed a claim arguing that the dentist ought to have ascertained the cause for her pain. The dentist and Boston Dental Group in Rockville where the practitioner was working were the main defendants (“Dental Malpractice Infection Lawsuit in Montgomery County.”). Upon detailed analysis on the plaintiff’s claims, it was deliberated that numerous mistakes were committed which included failure to prescribe appropriate antibiotics, poor diagnostic procedures and most importantly, failure to enter information into the patient’s chart.
Case Two in Georgia
In Georgia, a woman from Brantely County sought the help of a dentist to have her three teeth removed. However, the lady experienced numerous complications which included a deadly reaction to sedation (Bernard, 2018). For this reason, the woman developed a chronic medical condition, which stopped oxygen from reaching her lungs and blood. Resultantly, she died in the hospital, nine days later (Liu, Huang, & Liu, 2015). Upon further scrutiny of the dentist, 74-year old Dr. Graper, it was ascertained that there were numerous errors in the documentation of patient information. Dr. Graper failed to record the woman’s condition regarding reaction to sedatives, an aspect that would have allowed for application of relevant antibiotics after surgery. It was revealed that the majority of Dr. Graper’s patients were on Medicaid, with multiple and complex medical histories which were insufficiently documented (Bernard, 2018). On his side, the dentist stated he tried saving the woman’s life. The malpractice lawsuit led to a settlement of $675000 and revocation of Dr. Graper’s license.
Core Ethical Values and Relevance to the Cases
One of the evident core ethical values reflected in the two cases is errors in record keeping, which is tantamount to non-maleficence. Characteristically, the two patients involved contracted new problems while in the hospital setting, due to recklessness by medical staff. Fransen, Banga, van de Ven, Mol, and Oei (2015) avow that non-maleficence is likely to detriment their chances of quick recovery, and may be due to numerous shortcomings within a health organization, especially high employee turnovers. According to the American Diabetes Association (2015), patient-centeredness is paramount in ensuring recovery. The healthcare personnel did not exercise diligence through the errors evident in their records, an aspect that prohibited provision of effective drugs that would have alleviated the patients’ situations. For this reason, the two respective patients developed complications and eventual deaths at their venues of recovery.