Physicians and surgeons: medical records.

Plain English Breakdown

The bill summary does not provide information about enforcement mechanisms or specific consequences for violations, leaving these aspects unclear.

Doctors' Medical Records

The bill makes doctors responsible for their patients' medical documentation and prohibits anyone except the doctor from altering these records.

What This Bill Does

• Makes it clear that a physician's patient medical documentation, including notes about visits and treatment plans, is the responsibility of that physician.
• Prohibits anyone other than the authoring physician from altering, modifying, or editing patient notes, after-visit summaries, and diagnoses and treatment plans.

Who It Names or Affects

• Doctors and surgeons in California
• Patients who receive medical care

Terms To Know

Medical documentation

Information written down by doctors about a patient's health, including notes from visits and plans for treatment.

Unprofessional conduct

Actions that go against the rules set by the Medical Board of California for how doctors should behave professionally.

Limits and Unknowns

• The bill does not specify what happens if someone other than a doctor changes patient records.
• It is unclear who will enforce these new rules and how they will be enforced.
• There are no details on the penalties for breaking this law.

Official Summary Text

AB 1637, as amended, Caloza.
Physicians and surgeons: medical records.
Existing law, the Medical Practice Act, establishes the Medical Board of California to license and regulate the practice of medicine. A violation of the act is a crime, unless otherwise specified. Existing law makes it unprofessional conduct for a failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients for at least 7 years after the last date of service to a patient.
This bill would state that a physician and surgeon’s patient
medical documentation
notes, as defined,
shall be the responsibility of that physician and surgeon. The bill would prohibit a physician and surgeon’s
patient
notes, after-visit summaries, and diagnoses and treatment plans
notes
from being altered, modified, or edited in any fashion by anyone other than the authoring physician and
surgeon.
surgeon, except as specified.
By expanding the scope of a crime under the act, the bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

Current Bill Text

Download Bill PDF