What do Texas physicians have to document in the medical record after each visit?

I spent several hours today deposing a defendant surgeon in a medical malpractice case. My client, the surgeon’s patient, was left severely disfigured after the surgeon botched some elective plastic/cosmetic surgical procedures.

One of the focuses on the case is the surgeon’s lack of involvement in the preoperative planning, consent process, and surgical plan. From my experience in handling other health care liability claims against plastic surgeons, I wasn’t surprised to learn about the high-pressure sales staff or the hands-off surgeon.

As in many other cases, the patient was initially seen by a sales representative, rather than the medical professional. In fact, the patient wasn’t even allowed to see the surgeon until there had been a commitment and payment of the nonrefundable surgical fees.

As with any medical malpractice case, our investigation has centered around the relevant medical records. In this case, the key records came from the plastic surgeon’s office. According to those records, the surgeon first met with the patient a few days before the surgery.

At deposition, though, the surgeon told a story that’s quite different from what’s documented in his office medical record. I actually like the word that he used to describe his one and only note before surgery: “amalgamation.”

Although the patient has a clear memory of only meeting the surgeon once before surgery, the surgeon claims that he meant his one “amalgamation note” to include all of assessments and observations over a three-week period. On top of that, the surgeon claims that he didn’t do any of the documentation himself but left that to a scribe.

The Joint Commission, the nation’s oldest and most recognized health care accrediting agency, describes scribes as documentation assistants. The idea behind the scribe industry is that inexpensive staff members with limited training can assist physicians and surgeons by taking away the administrative burden of documenting in real-time electronic medical records. By spending less, documentation, doctors can see more patients and, thus, make more money.

That’s why this surgeon’s testimony makes no sense. How could he have used a scribe to generate even less documentation than the standard of care requires? That’s just fictional nonsense.

Texas Medical Board Rule 165.1 requires each licensed physician to maintain “an adequate medical record for each patient that is complete, contemporaneous and legible.” The rule mandates that an adequate medical record must at least include this documentation for each patient encounter:

• The reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.

• An assessment, clinical impression, or diagnosis.

• The plan of care.

• The date and legible identity of the observer.

In contrast to the clear requirements of the Texas Medical Board, this surgeon’s office chart includes undated, untimed, un-signed notes by unknown scribes. Then, of course, there’s the issue of the surgeon’s own self-professed amalgamation notes that summarize many weeks of care.

Based on my experience, I believe a jury will find the surgeon’s medical record to be so full of holes that a good portion of it is little more than speculation.

If you’ve been seriously injured because of poor medical or surgical care in Texas, then reach out to a top-rated experienced Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.