The licensee may appeal the Board's Final Order by seeking judicial review within 30 days of the filing of the Final Order. There are some suggestions which if closely adhered to may decrease a physician's risk of being investigated by the Department or disciplined by the Board. Your medical record documentation is your proof of the care you rendered and your defense against allegations of wrong-doing. The medical record is used for purposes of continuity of care, utilization review, peer review, criminal cases involving allegations of assault, rape, etc., medical malpractice defense, and defending against licensure discipline. It is advisable to document specifically because two to three years from now you will not remember specifics about the patient and the care you rendered to the patient.
Late entries are acceptable.
Simply identify the late entry as such and add the exact time of the entry. Do not hesitate to document when patients are non-compliant with your medical regimen. Never alter medical records. Altering the records implies you are guilty. Do not leave blanks or unchecked boxes on preprinted medical records.