This case study was made available to MIEC through our partnership with CRICO. It was written by Jennifer Vuu Sanchez, CRICO Description A 60-year-old male’s allegation of a failure to diagnose colon cancer was complicated by his undocumented refusals of recommended cancer screenings. Key Lessons Inadequate documentation of a patient’s refusal of cancer screening falls below the standard of care. A patient’s refusal of cancer screening, risks related to the refusal, and alternatives offered to the patient should always be documented in the patient’s medical record. Provide patient education on the importance of cancer screenings and document the patient’s level...
This case study was made available to MIEC through our partnership with CRICO. It was written by Margaret Janes, RN, JD, CRICO Description An elderly patient with a known history of mobility limitations fell and broke their hip after leaving the podiatrist's office with a newly applied walking boot. Key Lessons Copying and pasting of past assessments in the medical record may perpetuate erroneous or outdated information being carried forward. Be cognizant of what is new and what is no longer relevant. Repeatedly copied clinical notes may give the impression that you do not care about the patient. Where such...
Much of the discussion around patient privacy and confidentiality centers around appropriately restricting and securing access to protected health information, and this is for good reason- threats such as data breaches and cyber attacks often dominate the news, and medical practices are understandably concerned about the risks of litigation and bad publicity associated with privacy violations. It is important, however, to remember that patients have the right to access, and in some cases to direct others to access, their medical information in a timely fashion and at a reasonable cost. Providers own their physical records, but patients increasingly expect to have the ability to exercise their legal rights to the information contained in those records. Laws pertaining to medical...
Last updated: May 12, 2025 For various reasons, it may become necessary to close a medical practice. Unlike many other professions, the departure from office-based medical practice requires significant planning well in advance of the date set for closure. Common tasks include how to smoothly transition patients to another provider, who to notify of the closure, how to sell a practice and medical equipment, and what should be done with medical records. Because of the number and complexity of steps necessary to close a practice, we recommend a minimum of 90 days to properly discontinue the practice. Attorney Consultation...
One of the most common questions asked of MIEC’s Patient Safety & Risk Management Department is "how long physicians should maintain their medical records after a patient leaves the practice, or upon retirement?" While many might assume that there are clear laws and regulations around this issue, in fact, there are few laws that address it (please see the table below for information on state laws). MIEC’s recommendations are as follows: What Attorneys Advise “Keep medical records forever.” This is the advice of many malpractice defense attorneys, because in the event of a medical malpractice claim, the medical records...