Legibility Requirements for Medical Records

Posted on: July 26, 2017
medical records

In Florida, the Medical records standard requires that all medical records be legible or otherwise they may be subject to disciplinary actions by the Florida Department of Health.

Many providers have thus opted to have their notes typewritten in order to ensure the legibility of their records.

There are some providers however who still put all of the medical notes in their own handwriting which may lead to problematic issues if the handwritten notes are subjectively deemed illegible or if the provider keeps both handwritten and typewritten notes.

HANDWRITTEN NOTES
As a practical matter, the penmanship of a medical professional tends to wane after a long day of seeing patients.

medical records

Handwritten notes are also vulnerable to attacks by insurance companies for not being subjectively legible for example: “handwriting too small to read” or “unable to read diagnosis code”.

While the report may be clearly legible to the common person, handwritten notes give an insurance company an excuse to deny payment.

In some instances a PIP Insurer may in fact be able to legally stall payment for services by issuing a pre-suit discovery request under Florida Statute 627.736(6) (b) aka a “6b Request” asking for clarifying documents to explain what is written on the medical report.

In other instances, an insurer may force you into court like in the case of Chambers Medical Group, Inc. aao Marie St. Hillare vs. Progressive Express Insurance Co., 14 Fla. L. Weekly Supp. 207a Fla. 13 Cir. Ct. (App. 2006) in order to obtain a court ruling on the legibility of a document.

Either way handwritten notes by themselves may inflict unnecessary headaches without there being typewritten legible copies of the medical records.

HANDWRITTEN NOTES AND TYPEWRITTEN NOTES
Even if a medical professional keeps both hand written records AND typewritten records, they may be giving an insurance company the perfect delay tactic.

In a PIP scenario, for instance, if the medical provider only submitted their typewritten notes, the PIP Insurer may issue a pre-suit discovery requests under a 6b Request for the handwritten medical notes.

Until a formal response sending the PIP Insurer the written sets of notes is made, the PIP Insurer may not be obligated to pay anything on the claim.

If the provider did not include everything on the handwritten notes or added something to the typewritten one, the case may get denied for that reason alone until the discrepancy is explained.

All supporting documentation for a medical provider’s treatment and billing should be provided as order to explain any discrepancies and show compliance under Florida law and regulations.

To learn more about your legal rights and how our personal injury attorneys may be able to help, please call 1-800-984-9951 or contact us here to set up your free consultation.

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Author: FLLegalGroup
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