Standards In Colorado Medical Records Documentation

The Importance of Accuracy and Standardization

Among the primary purposes for medical records documentation are to ensure that the patient receives high quality healthcare and that there is a seamless transfer of information when a patient is handed off to another physician or dentist or other healthcare professional.

As a medical professional attorney who represents doctors, physician assistants, nurses, and clinic and hospital administrators in the Denver area and throughout Colorado, I have seen medical and dental records become an issue many times in my client’s cases.

Being able to show that medical records are accurate, thorough, and consistent is invaluable when representing my clients and protecting them against complaints and claims.

Medical Records Practices for Colorado Doctors

  • Medical records should be thorough, current, legible, and comply with the Colorado Medical Board’s requirements. Dental records and other healthcare professional records should follow similar standards and are subject to the rules and polices of the healthcare professional’s licensing Board. Additionally, supporting documentation should also be included in a patient’s chart (i.e. emails, letters, et cetera). Any interaction between a patient and the doctor, physician assistant, nurse, assistant, tech, and even many staff members should result in a timely entry in that patient’s medical record.
  • Doctors and nurses should refrain from using any language, jargon, or abbreviations that would not be easily recognized by another healthcare professional in their respective field. With this goal in mind, the individual making an entry into a medical or other healthcare record should consider whether his or her entry would be readily understood by another doctor, nurse or other healthcare professional.
  • Incomplete medical records are particularly difficult to defend in a disciplinary action by the the professional’s licensing Board. Licensing Boards that receive a complaint against a doctor or other healthcare professional for other issues will often discipline the professional for poor patient charting, even when they dismiss the original complaint. Poor charting practices are even more problematic in the event of a civil lawsuit.
  • Regardless of whether an entry is made via a computer, written by hand, or dictated for transcription, there should not be a substantial time delay after the event that prompted it. Delays in recording information often lead to omissions and errors in medical records, as well as challenges to the validity or accuracy of the records.
  • And while a flawed medical or dental record may not necessarily result in an unfavorable outcome for a physician, dentist, or other healthcare provider, it almost always raises a red flag in a civil suit.

Colorado Medical Records – Board Requirements

The state of Colorado has specific guidelines when it comes to the origination, retention, and dissemination of patient medical records. Healthcare practices and doctor’s offices should meticulously adhere to Colorado’s laws and the regulatory agencies policies that affect them.

When establishing medical records practices, the administrators of doctor’s offices and hospitals should consult with a medical professional attorney—like Philip M. Bluestein of Boulder, CO—to assist in establishing Board-compliant practices. Furthermore, all employees involved in maintaining or distributing medical records should receive training and periodic refresher training.

The foregoing is for general informational purposes only and is not intended, nor should it be construed as legal advice. No attorney client relationship is formed by this article. If you are seeking legal advice regarding your specific questions, you may contact Philip M. Bluestein directly at (720) 420-1777 or by email.