Physicians and surgeons: medical records

The law assigns responsibility for patient notes to the physician who authored them and limits who may change them. Unauthorized alteration can constitute unprofessional conduct under the Medical Practice Act.

What the law does ​

• Defines patient notes as notes, after-visit summaries, and diagnosis and treatment plans.
• Makes a physician responsible for their patient notes in every clinical setting.
• Bars anyone but the authoring physician from altering, modifying, or editing those notes, with specified exceptions.
• Allows authorized scribes, medical assistants, and other delegated personnel to edit notes under the authoring physician’s authority.
• Allows a receiving physician to add to notes after a patient’s care is transferred.
• Allows supervising physicians to edit notes by supervised trainees, interns, residents, and postdoctoral fellows.

Who it affects ​

• Physicians and surgeons.
• Scribes, medical assistants, and other authorized clinical staff.
• Physicians supervising medical trainees and physicians receiving transferred patients.