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Court Denies Appeal Related to Failure to Maintain Medical Records

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In an opinion filed June 11, 2013, a three judge panel of the Commonwealth Court of Pennsylvania affirmed the State Board of Medicine's imposition of civil penalties upon a physician for failure to maintain medical records as required by the Medical Practice Act of 1985. 

In the underlying case, a physician contracted with a commercial company for the purpose of reviewing online prescription requests.  Under the terms of the contract, from 2009 to 2011, the physician filled the requests based on online questionnaires completed by customers of the company.  The questionnaires set forth information such as the reason for the request and the patient's medical history.  Additionally, the company also provided the physician with access to an online database that contained copies of the patients' medical records. 

During the course of his contract, the physician conducted his reviews solely from the online documents and did not print or retain in his own personal office any of the patients' medical records, questionnaires, or files. 

In April 2011, the State Board of Medicine issued an order to show cause alleging that the physician had engaged in unprofessional conduct by failing to maintain medical records relating to the patients for whom he filled prescriptions.  Under the relevant provisions of the Medical Practice Act of 1985, a physician is required to "maintain medical records for patients which . . . reflect the evaluation and treatment of the patient."  63 P.S. 422.1-422.51(a).  Because the physician did not personally keep his own medical records with regard to his patients, the Board alleged that he violated the Act and in turn, imposed a $2,500 civil penalty.  The physician was also required to complete ten hours of continuing education in the area of medical recordkeeping.

The physician subsequently appealed to the Commonwealth Court, stating that the Board misinterpreted the portion of the Act which addressed the maintenance of patient medical records. 

On review, the court affirmed the Board's order, holding that the pertinent section of the Act could reasonably be interpreted to require the physician to have "possession" of his patient's medical records.  While the physician argued that the Board's interpretation of the Act ignored the realities of modern medical practice "where the employers and not the physicians maintain patient medical records," the court noted that such circumstances were already contemplated by the Act, as part a provision excusing this requirement where the records "are retained by a health care facility." 


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