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Complaints filed with the TMB can disrupt physicians’ careers, tarnish reputations, and lead to disciplinary actions. However, many complaints are dismissed before reaching the formal investigation stage—often because accurate and complete medical records support the physician’s position.
At Gardner Employment Law, we understand the importance of accurate medical records. If you have questions about record keeping or the TMB complaint process, read on.
What Role Do Medical Records Play in the TMB Complaint Process?
Accurate medical records can help a physician avoid having a complaint even being formally filed by the TMB. Good medical records form the foundation of a strong defense when a complaint arises. They capture every critical detail of a patient’s care—documenting the diagnosis, treatments, communications, and follow-ups. These records demonstrate that care was provided in accordance with professional standards, giving the physician the opportunity to counter any allegations that may be raised.
Thorough records are especially crucial because complaints in Texas often involve questions about the standard of care. If a patient or their family alleges negligence or improper treatment, the physician can use the medical records to provide evidence of the rationale behind clinical decisions. Patients and family members often do not understand that, while medicine is a science, it takes a physician’s good judgment and experience to know how to apply those scientific principles. The medical records lay out the facts that were facing the physician when he or she encountered the problem and what was done.
Medical records also establish a timeline of interactions, showing that the patient was informed about their care, understood the risks, and gave consent. This transparency builds trust and credibility during the complaint evaluation process. Conversely, missing or incomplete records leave room for doubt, making it difficult to demonstrate compliance with best practices.
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- Well-maintained medical records allow for: Clear documentation of care: They explain why certain treatment choices were made and verify that they were appropriate.
- Proof of compliance with protocols: They confirm adherence to legal and ethical standards.
- Efficient complaint resolution: Boards rely on organized records to assess cases quickly, often leading to early dismissal of complaints.
Why is the 28-Day Response Window to the TMB’s Notice Letter Critical?
When the TMB receives a complaint, it must complete an initial evaluation within 45 days. During this phase, the TMB decides whether to dismiss the complaint or advance it to a formal investigation. After the TMB notifies the physician of the complaint, he or she has 28 days to respond with relevant documentation—primarily medical records— to support the action taken.
You must use this 28-day window to demonstrate compliance with professional standards. A well-prepared response containing detailed records can persuade the initial decision maker reviewing the file that the complaint lacks any merit. If that is the conclusion, the TMB will not formally file the complaint. The physician’s record is “clean.” For example, if the complaint alleges poor communication or improper care, the physician can point out his or her contemporaneous notes in the medical file showing that the patient was informed of risks, that you offered alternatives, and that the patient consented to the course of treatment that you recommended.
If you miss the 28-day deadline or submit an incomplete response, the complaint likely will advance to a formal investigation. This could expose you to public scrutiny, legal penalties, and damage to your professional standing. Therefore, take timely action, especially sending your lawyer the medical file, to avoid escalation.
How Can Accurate Medical Records Prevent a Complaint from Escalating?
Strengthening Your Defense with Medical Records:
| Defense Strategy | Description |
| Demonstrating Standard of Care | Precise records show clinical decisions, treatments provided, and professional reasoning. |
| Providing a Patient Communication Trail | Captures interactions, including discussions of risks, options, and follow-ups to refute miscommunication claims. |
| Minimizing Gaps in Documentation | Comprehensive records offer a clear narrative of care, reducing doubts. |
Below are suggestions to help you apply best practices in good record-keeping:
| Practice | Details |
| Document Patient Encounters in Real Time | Ensure accuracy and prevent forgotten details. Motto: “Do it now.” |
| Be Detailed and Precise | Include symptoms, diagnoses, tests, medications, and follow-ups. Gaps raise red flags with TMB investigators. |
| Track Informed Consent | Record discussions on risks and alternatives. Take time to explain risks to avoid misunderstandings. |
| Use Secure, Organized Systems | Digital platforms aid access and organization but beware of “operator error.” |
| Be Consistent | Review all staff entries and ensure consistency across encounters. Check that today’s entry aligns with previous records. |
By following these practices, healthcare professionals position themselves to respond effectively to complaints and demonstrate their adherence to legal and professional standards.
Contact an Expert.
Receiving a notice from the TMB can feel daunting, but accurate medical records are your first line of defense. When maintained properly, these records provide the evidence needed to resolve complaints early, often preventing them from being formally filed. If you have questions or concerns, contact us today.