Physicians and surgeons: medical records., the official text

An act to add Section 2266.1 to the Business and Professions Code, relating to healing arts.

LEGISLATIVE COUNSEL'S DIGEST

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 notes, as defined, shall be the responsibility of that physician and surgeon. The bill would prohibit a physician and surgeon’s patient notes from being altered, modified, or edited in any fashion by anyone other than the authoring physician and 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.

The people of the State of California do enact as follows:

SECTION 1.
Section 2266.1 is added to the Business and Professions Code, to read:
2266.1.
(a) For purposes of this section, “patient notes” means notes, after-visit summaries, and diagnosis and treatment plans.
(b) A physician and surgeon’s patient notes shall be the responsibility of that physician and surgeon, regardless of the clinical setting.
(c) A physician and surgeon’s patient notes shall not be altered, modified, or edited in any fashion by anyone other than the authoring physician and surgeon or any of the following:
(1) A scribe, medical assistant, or other authorized individual acting under the authority delegated by the authoring physician and surgeon.
(2) A physician and surgeon who is adding to an authoring physician and surgeon’s patient notes if patient care has been transferred from the authoring physician and surgeon to the physician and surgeon who is making the additions.
(3) A physician and surgeon altering, modifying, or editing the patient notes of a physician and surgeon postgraduate training licensee, intern, resident, or postdoctoral fellow who the physician and surgeon is supervising.

SEC. 2.
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.