Physicians close their practices for a variety of reasons. They may sell or merge with a larger practice or hospital, retire or become ill and die. Independent and rural practices are particularly at risk for closure and acquisition.

When changing an entry on an electric medical record, avoid obliterating or overwriting the original entry. This could lead to misinterpretation of the original entry and the possibility of tampering with the record.

Definition

The Medical Record is defined as all documentation of a patient’s care and treatment, including but not limited to, photographs, films, digital images, fetal monitor strips and written or dictated reports. The documentation may be in paper or electronic format.

Entries on the Medical Record should be made clearly and legibly, especially when the entries are handwritten. Skipping lines may leave the entry susceptible to tampering. When corrections are necessary, they should be inserted rather than overwriting the original. The original entry must be authenticated and dated by the author.

The Medical Record is confidential and protected from unauthorized disclosure by law. The patient or the patient’s representative has a right to inspect the Designated Record Set and to receive copies of records. Physicians may charge for the cost of copying and clerical costs associated with the search of their records. The Legal Medical Record is a subset of the Designated Record Set and can be released for legal proceedings.

Purpose

A closed record may be useful for a number of reasons. It can be used to track and manage a patient’s progress, for example through treatment or as evidence of care provided during a medical negligence case [1].

In order to prevent patients from being denied access to their records, medical staff should carefully consider how they mark entries. For example, attempting to obliterate an entry by using whitener will create ambiguity that may lead to the assumption that the omission was done with intent to conceal evidence of malpractice [2].

Closed files are retained for periods laid down in procedures manuals and when this period expires they should be transferred to the Records Centre. The staff at the Records Centre are responsible for carrying out all subsequent procedures laid down for these files including retrieval for use, review and if necessary destruction or transfer to the Archives Repository [3].

Significance

Practices can close for a number of reasons. Physicians may merge with a larger health system, they may retire, or they may sell their practice. The COVID-19 pandemic may have caused financial distress to small, independent practices and rural practices, leading to their closure or sale.

When a file is closed, the word “closed” should be stamped on the outside of the folder and the date of closure noted in the index. The files should be stored in a designated area and according to accepted standards.

If an entry is erroneous, instead of overwriting it, strike through it. Overwriting an entry raises suspicion that the document was tampered with. Entries should always be clearly legible and accessible to someone other than the author. In the case of electronic records, entries should be dated and signed to avoid any potential tampering.

Extent

The medical record can physically exist in multiple locations and formats, including paper and electronic. Physicians may also use Macros to repeat a sequence of keystrokes to document an entire medical note, saving on transcription costs and eliminating repetitive documentation time. Many independent practices, particularly those in rural areas, do not have an EHR. Closure of a practice occurs for a wide range of reasons: physicians may merge with larger organizations or health systems, retire, become incapacitated or die, or the COVID19 pandemic has financially challenged smaller practices, leading to closure or acquisition by other providers. Physicians are required to notify patients before a practice closes or is sold.