Certificate of Completeness

SUBMISSION OF “CERTIFICATE OF COMPLETENESS OF MEDICAL RECORD”:
IN FLORIDA DEPARTMENT OF HEALTH (DOH) INVESTIGATION

Many of our physician clients ask us about submitting a Certificate of Completeness for a copy of a medical record their office has provided during an on-going Department of Health (DOH) investigation. These indicate that they must be signed under oath and notarized, with the physician swearing that the copy provided to DOH is the complete record.

First, we strongly recommend that you retain the services of an experienced health attorney who handles Board of Medicine cases and Department of Health complaints. Sometimes the letters or documents are signed by a person with a job title of “Medical Quality Assurance Investigator” or “Medical Malpractice Investigator.” These are actually investigators who investigate complaints that may result in disciplinary actions against a physician’s medical license.

Second, we do not allow our clients to sign and submit such “Certificates of Completeness of Medical Records.” We have seen these used against physicians in cases in which a complete copy was not made or submitted, or in which additional documents from the medical record were later discovered or obtained from the hospital, diagnostic facility or consultant. They are used to attempt to prevent the introduction of additional documents later, at a hearing, for example. They may also be used against the physician to prove a disciplinary charge, for example, that the “complete copy” provided did not contain medical documentation considered to be necessary.

Although these forms sometimes refer to a Florida law that requires this, we could find no such law.

Physicians often delegate copying of medical records to low-paid or untrained administrative staff. Often they do not copy the complete record. If the physician himself has not copied the original record, checked the copies for completeness and knows exactly what is being sent to the investigator, he should not be swearing to this. Additionally, “complete record” means just that, the entire record, every entry and every document which it contains.

Our firm has an exacting policy regarding checking, page numbering, labeling and copying medical records we produce for a client, including ensuring copying of the backs of forms and reports, informal notes and “stick-ons,” and the front and back covers of the medical record (for paper medical records). We always keep identical copies of what is sent out for future reference. An investigation against a physician may result in charges related to improper record-keeping practices, missing medical records, or other charges, even if the original complaint is found to be without merit.

Our advice is to retain the services of an experienced health attorney who handles Board of Medicine cases and Department of Health complaints. Let your attorney take care of this and be involved from the beginning of an investigation.

(revised 2/20/2011)

This is for information purposes only and does not constitute legal advice.

Copyright 2011 George F. Indest III, Board Certified by The Florida Bar in Health Law, The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, Florida 32714. Phone: (407) 331-6620. All rights reserved.