QUESTION:        A physician on our staff has made numerous inappropriate entries into our patients’ medical records. These include scathing critiques of other practitioners and even nasty comments about his patients and their families.  While we have approached him several times to inform him that a patient’s medical record is not an appropriate forum for these comments, he claims he has the First Amendment right to put whatever he wants to in the records, and continues to do so. What can we do?

ANSWER:            Regulatory and accreditation standards make it clear that medical records should only be used to document objective clinical information relative to a patient’s care. Inappropriate editorial statements in a patient’s medical record that are used to be critical of the patient, other providers, or even the hospital itself do not advance the care of a patient and may create increased legal risks to everyone involved in that patient’s care.

A physician who has a complaint or concern regarding the care being provided by any other individual should be advised that the medical record is not the proper forum for addressing those concerns and should then be directed to the appropriate medical staff or administrative channels to report them.   Most times, providing this education and counseling to the physician is sufficient to resolve the issue.  However, if the inappropriate entries continue, then the matter should be referred for review under the medical staff’s Professionalism Policy or Code of Conduct.

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