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Legal Case Review: Case Summary: Fernando Jimenez M.D. v. Department of Professional Regulation Board of Medicine (4th Cir. 1990)

Cristina Palacio, Esq.
2-1-5 This case involves an appeal by the above physician, of a disciplinary penalty imposed by the Board of Medicine that was more severe than the penalty recommended by the Administrative Hearing Officer of the Division of Administrative Hearing. The allegation below came to light following a medical malpractice suit where it was discovered that the plaintiff had obtained two copies of the same medical record which were found to differ. One of the copies contained added documentation that the above physician had advised the patient to have a stress test and an angiogram and that the patient had refused the recommended tests. There was no notation that this additional documentation was a late entry.  After a hearing on the matter, an administrative hearing officer concluded that the above physician: (1) added the exculpatory documentation nearly a year after providing the documents to the plaintiff, subsequent  to the initiation of the DPR investigation; (2) had filed false reports, because the addition was not denoted as a late entry; (3) violated statutory requirements for written records justifying the course of treatment; (4) added documentation only to forestall any criticism relating to his failure to have the patient undergo a stress test and angiogram; and finally, (5) was guilty of malpractice. The administrative hearing officer recommended to the BOM that the above physician be placed on probation for 1 year and fined $5,000, however, the Board of Medicine suspended the physician’s license for one year and placed him on probation for two years in addition to the $5,000 fine.  The Florida Court of Appeals affirmed the subsequent Board of Medicine action.   Allegation: Knowingly filing false medical reports, failing to keep written medical reports justifying the course of treatment of a patient by making deceptive, untrue and fraudulent representations in the practice of medicine, and failure to meet the standard of care.   Case Analysis: This case clearly demonstrates the importance of maintaining accurate medical records, not just for patient care reasons, but to avoid several bases for liability, the most damaging of which was the finding of deliberate falsification in an effort to avoid malpractice liability. Not only is such activity unethical, as noted by DPR, it is a crime under Florida state law. F.S. §395.302 provides that any person who fraudulently alters, defaces or falsifies any medical record commits a misdemeanor of the second degree. The fraudulent alteration finding could have been based on two separate acts. The most obvious was the fact that the above physician never advised the patient to get a stress test and angiogram. Even if the defendant had indeed properly advised his patient, his late entry, without any indication that it was a late entry, could also be considered a violation of F.S. §395.302.   Risk Reduction Strategies: Physicians have a statutory duty under F.S. §458. 331 and F.S. §459.015 to maintain medical records “that justify the course of treatment of the patient, including, but not limited to, patient histories; examination results; test results; records of drugs prescribed, dispensed or administered; and reports of consultations and hospitalizations.” Physicians who do not comply with the requirement are subject to disciplinary action.  Therefore, medical record documentation should not only be accurate and timely but complete with all medical record entries dated to reflect when the entry was made, even if it relates to an event that occurred earlier than the documentation date. Even late entries, where clearly identified as such, and justified, can provide important documentation to support a physician’s claim that appropriate care was provided.