SPONSOR: Byrnes
This bill establishes the "Missouri Medical Documentation and Patient Recording Accountability Act".
It requires all clinical communication influencing patient care to be documented within the same calendar day or within 24 hours if occurring outside the regular business hours of a health care provider, and provides that no clinical decision, diagnosis, exclusion, refusal of testing, psychiatric attribution, or change in care plan for a patient is valid unless documented. Any electronic communication related to patient care must be automatically retained and incorporated into the patient's medical record, and cannot be stored outside of the medical record.
The bill prohibits a health care professional from attributing a patient's symptoms to psychiatric or psychosomatic causes or making a diagnosis of functional neurological disorder, conversion disorder, or somatic symptom disorder unless the professional performs a differential diagnosis, orders testing to rule out other conditions, performs a physical examination and documents the findings, and documents the rationale for the attribution or diagnosis in the patient's medical record.
The bill allows a patient or a patient's family to request documentation or clarification of any clinical communication, which must be provided within 72 hours of the request being made.
The bill prohibits a health care provider from:
(1) Making or relying on undocumented clinical decisions;
(2) Delaying care based on undocumented psychiatric assumptions;
(3) Using internal messaging as a substitute for documentation in the patient's medical record;
(4) Deleting, auto-purging, or concealing internal communications; or
(5) Creating systems bypassing documentation requirements.
A health care provider that violates the provisions of this bill will be punished as follows: (1) For the first violation, the provider is guilty of a class D misdemeanor;
(2) For the second violation, the provider is guilty of a class A misdemeanor; and
(3) For the third or subsequent violation, or any violation resulting in harm to a patient, the provider is guilty of a class E felony.
Additionally, a provider that intentionally deletes internal communications in violation of the provisions of this bill will be guilty of a class D felony, and a health care facility that enables undocumented communication in violation of this bill will be subject to a civil penalty of up to $50,000 for each violation.
The bill allows a patient or the patient's advocate to audio record, video record, or live stream any part of the patient's medical encounter. A health care provider is prohibited from interfering with any recording or live streaming except to protect the privacy of other patients, prevent the obstruction of a procedure, or maintain sterile environments. Unless the patient refused recording or live streaming, the patient's advocate can record even if the patient is unconscious, sedated, mentally impaired, or under psychiatric evaluation. A health care facility is prohibited from retaliating or taking certain actions based on a patient's or advocate's exercise of the right to record or live stream the encounter. A provider that interferes with any recording or live streaming is guilty of a class A misdemeanor, unless the provider interfered for the purpose of concealing the medical encounter, in which case the provider is guilty of a class E felony.
Each health care facility must post a printed sign with the following text:
"Patients have the right to record communications and care involving their treatment."
Any health care provider that retaliates against an employee for reporting a violation of the provisions of this bill will be guilty of a class D felony.
Statutes affected: