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Medical Records Basics


Understand the legal obligations and duties arising from the use and retention of medical records.

It may seem the term 'medical records' is easy to define and that the professional and legal obligations related to their creation, use, and retention are rather straightforward. However, it is not so simple once one considers the responsibilities mandated by the highly regulated health care industry that is creating and maintaining those records and when rights to their ownership and access are asserted. In reality, the term 'medical records' is not a one-size-fits-all definition but rather encompasses varying duties and obligations that are dependent upon the patient, their illness, and type of provider. This material will help those who create and use medical records on a regular basis understand the legal obligations and duties arising from their use and retention. It will explore what constitutes a medical record and who may assert claims to their access and ownership. A discussion on best practices will be valuable to ensure proper standards and compliance are met. Case studies will be used to further illustrate when problems may arise and how planning and training may reduce the likelihood of an adverse event occurring. It is critical that individuals and employers who regularly work with medical records understand what is necessary to meet these obligations and anticipate issues that may arise in their use.



Patrick D. Souter

Patrick D. Souter

Gray Reed & McGraw LLP

  • Of Counsel, Gray Reed & McGraw LLP
  • Representation of physicians, hospitals, and ancillary providers in operational, regulatory, and administrative matters
  • Board certified in health care law by the Texas Board of Legal Specialization
  • Adjunct professor of health care studies at Baylor University School of Law and frequent speaker to national and local health care organizations
  • Recognized as a leading health care lawyer in Texas by Chambers & Partners USA (2020) and selected by his peers for inclusion in Woodward/White, Inc.'s The Best Lawyers in America in the field of health care law (2019 - 2021)
  • Frequent author of books and articles for the American Health Law Association (AHLA) and American Bar Association (ABA) including co-authoring the AHLA’s Representing Physicians, 4th edition and the ABA’s Physician Law Evolving Trends and Hot Topics (2017- 2020 editions) and What is ... Medical Staff Peer Review?
  • Frequent speaker on physician, hospital, and other provider issues
  • Member of the American Bar Association, State Bar of Texas, American Health Law Association, American College of Healthcare Executives, and Health Care Compliance Association
  • LL.M. degree in health law, Hofstra University; J.D. degree, Baylor University School of Law; M.B.A. degree in health services management, University of Dallas
  • Can be contacted at 214-954-4135, [email protected] or 1601 Elm Street, Suite 4600, Dallas, Texas 75201

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