June 2003

Record keeping for family members and employees

by Timothy Feuling

By now, everyone should understand the importance of maintaining complete and accurate records on every patient who receives care. (For more information on this topic, see the CBS report, Tips for Better Record Keeping, www.cbsmalpractice.com/report/articles/jul1101.htm).

However, many doctors don't realize that EVERYONE they adjust is legally considered a patient. This includes employees and even family members. If you adjust your spouse, parents, or children, they are patients ‑‑ and you need to maintain the same type of records on them as you would for "paying customers."

This might sound excessive. After all, it is extremely improbable that your mom, dad, son or daughter would ever sue you (I deliberately didn't put your spouse on this list since bitter divorces can turn once‑loving life partners into enemies, and more than one lawsuit has been filed against doctors by spouses hoping to hurt their ex or benefit financially.)

But lawsuits are only one of the scenarios you may face in this situation. A more likely one is a board complaint. A recent case in Maine, for instance, involved a chiropractor who was called before the board when another D.C. complained about his newspaper ad. As part of the board's investigation, the doctor was interviewed in his office. Although it was totally unrelated to the question of advertising, he mentioned ‑‑ with pride ‑‑ that he routinely adjusts his wife and two children. "Can we see copies of their records?," the investigator asked.

"I don't keep records on them, they're just my family," the doctor responded.

In his eyes, they were "just family," not real patients. But to board investigators (and the courts), anyone who receives your care is a patient and you must keep records on them.

This is true of employees as well. Many D.C.s offer adjustments as a fringe benefit of employment, and it's a great way to keep staff members healthy and happy. But while the individual is at your front desk, she or he is an employee. On your adjusting table, the same person is a patient. If that employee/patient ever sues you (as disgruntled employees have been known to do), or if the board investigates and finds you cared for someone without keeping records, your license and assets may be in jeopardy.

The bottom line is, any time you have a doctor‑patient relationship ‑‑ and that is every time you provide professional services ‑‑ you are vulnerable to a lawsuit and subject to your state's laws and regulations. There are no exceptions. And that means there can be no exceptions to the need for records. To fully protect yourself, keep records on everyone you adjust or provide health care to ‑‑ including employees, family members, and friends.

(Timothy J. Feuling is president of Chiropractic Benefit Services (CBS) and vice president of the World Chiropractic Alliance. He assists doctors in maximizing their practices through the proper choice of insurance and related services. Doctors may contact him with questions, comments, and requests for insurance quotes at 2950 N. Dobson Rd. Ste. 1, Chandler, AZ 85224, by phone at 800‑883‑0412 or by e‑mail: feuling@cbsmalpractice.com).