What Do I Need to Know About Keeping My Own Patient Visit Records?

Carolyn Buppert, NP, JD


June 08, 2005


I am attempting to keep my own accurate figures regarding numbers of patients seen, percentages of various CPT (Common Procedural Terminology) levels billed, and percentages of specialty and nonspecialty patients seen (the practice sees both). Do I have a legal right to these figures as compiled by the practice's billing company or office manager? Are there legal issues related to photocopying charge slips for my own records?

Laura O'Donnell, MS, CANP

Response from Carolyn Buppert, NP, JD

The practice is not obligated to give you their billing, collections, or accounting records. Some practices do and some don't. You certainly can, and should, keep your own records so that you can figure your total billings per year and use that number to negotiate terms of employment and/or to document your value to the practice.

If you are going to photocopy slips that contain patient health information and if your practice falls under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) patient privacy regulations, you need to be sure to safeguard those records from review by individuals who are not involved with the patient's treatment, payment, or the practice's operations. Practices that bill patient visits electronically are subject to HIPAA regulations.

Also, if you have signed an employment contract, make sure you have not agreed, by contract, not to copy such documents.

If your employer finds out that you are copying charge slips, he or she may order you to stop, saying those slips are proprietary to the practice. If that happens, it is advisable to stop. However, no one can stop you from keeping a list of the names of patients you see, the dates of the visits, and the CPT codes you selected. You can apply a fee schedule to that list and come up with your own accounting of billings attributable to you, per month, quarter, or year.

Or, you may want to use a tool such as NP Data Tracker 2.0, a software program that enables the user to track revenues the NP generates, and to print periodic reports (see footnote).

Footnote: For more information about NP Data Tracker 2.0, visit https://www.shepherdent.com/NPDataTracker2.htm or https://www.buppert.com/ .


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