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can a dr copy & paste an old note from another dr into their note and use the exam w/o performing their own?
Saint Petersburg, FL
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Posted 3 months ago in Medical Malpractice
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my new neurologist copy&pasted the office note from my old neurologist office vist from 1 yr 4 months ago into the office note for today. She edited some parts and added a few things, but she did not perform an exam, and she left in the physical & neuro exam part of the previous exam. Isn't this against the law? She just recorded into my medical record tests and findings for things she didn't test for.
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Answers (2)
Lars A. Lundeen
This attorney is licensed in Florida and 1 other state.
Posted 3 months ago.
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Often times doctors will use previously dictated notes as a backbone for some of their own writing, however, if a doctor did not perform an examination and yet documents her records, stating that she did, this is improper. However, I suspect that you will have a very hard time proving it.
Legal Disclaimer: Mr. Lundeen is licensed to practice law in Florida and Vermont. The response herein is not legal advice and does not create an attorney/client relationship. The response is in the form of legal education and is intended to provide general information about the matter in question. Oftentimes the question does not include significant and important facts and timelines that, if known, could significantly change the reply and make it unsuitable. Mr. Lundeen advises the questioner to confer with an attorney in their state in order to ensure that proper advice is received. 
Dennis Michael Phillips
This attorney is licensed in Florida.
Posted 3 months ago.
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Change doctors and make sure that you get an actual neurological and physical examination. This doctor may very well have fallen below the standard of care; but unless it caused damages to you, you don't really have a medical negligence claim worth pursuing. However, you may want to file a complaint. Follow this link and scroll down to the bottom of the page for the appropriate complaint form: http://www.doh.state.fl.us/mqa/enforcement/enforce_csu.html
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