Many doctors consider the possibility of a disciplinary action based on inadequate or improperly kept medical records to be remote. Yet, the Texas Medical Board will oftentimes use a complaint based on other grounds, such as an alleged standard / quality of care violation, as an opportunity to thoroughly investigate a licensee’s compliance with Board Rules concerning the maintenance of medical records. Even if the original complaint is found baseless, the TMB has the right to pursue disciplinary sanctions for any other violations found during their investigation, and in a quality of care case this investigation will certainly include a thorough review of medical records.
Under the Texas Administrative Code, the Texas Medical Board has adopted official agency rules regarding the proper maintenance of medical records. For example, § 165.1 contains numerous mandatory guidelines concerning the maintenance of “adequate medical records.” Title 22 Texas Administrative Code § 165.1. Moreover, pursuant to the Medical Practice Act, the TMB has the same authority to pursue the full range of disciplinary sanctions for non-compliance with this provision as it does for any other Rule. Texas Occupations Code § 164.051(a)(3).
When the Board initiates an investigation into a complaint, they are searching for any breach of either the Texas Medical Practice Act or TMB Agency Rules, not only for evidence regarding the original allegations. Unsurprisingly this investigation will include a searching review of medical records completed and maintained by the physician. This is all the more true with quality of care cases where a final determination will necessarily involve an expert review(s) of the relevant records. At this point the Board may decide that no clinical breach in the quality of care occurred, however, they can, and frequently will, next initiate a licensure action regarding improper medical documentation. The Board will then pursue a sanction such as placing the doctor’s license on probationary status complete with onerous conditions that can remain in force for years. Further, any disciplinary action will likely remain part of the licensee’s record and could trigger mandatory reporting requirements to other state licensure boards, the National Practitioner’s Database, and the doctor’s place of practice. Texas doctors need to be aware of this stepping-stone potential and its latent consequences.