STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF PROFESSIONAL ) REGULATION, BOARD OF MEDICAL ) EXAMINERS, )
)
Petitioner, )
)
vs. ) CASE NO. 86-0995
)
ZEVART MANOYIAN, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, the Division of Administrative Hearings, by its duly designated Hearing Officer, W. Matthew Stevenson, held a formal hearing in this cause on September 18-19,1986 in Miami, Florida. The following appearances were entered:
APPEARANCES
FOR PETITIONER: David E. Bryant, Esquire
1107 East Jackson Street, Suite 104
Tampa, Florida 33602
FOR RESPONDENT: Michael I. Schwartz, Esquire
119 North Monroe Street Tallahassee, Florida 32301
The issue in this case is whether or not the Respondent's license to practice medicine should be disciplined for alleged violations of Chapter 458, Florida Statutes, as set forth in the Administrative Complaint. In three separate counts, the Administrative Complaint charges that Respondent prescribed controlled substances other than in the course of her professional practice, failed to keep written medical records justifying the course of treatment of her patients and committed gross or repeated malpractice and/or failed to practice medicine with that level of care, skill and treatment which is recognized by reasonably prudent similar physicians as being acceptable.
PROCEDURAL BACKGROUND
The Administrative Complaint was filed with the Department of Professional Regulation on February 27, 1986. The Respondent disputed the allegations of fact contained in the Administrative Complaint and requested a formal hearing before a hearing officer appointed by the Division of Administrative Hearings. This cause came on for final hearing on September 18-19, 1986. The Petitioner called the following witnesses: A. Lichtenstein, DPR Investigator; John W. Handwerker, M.D. (accepted as an expert in the area of family medicine); Jeffrey Matthews, DPR Investigator; and, Daniel W. Frazier, M.D. (accepted as an expert in the area of family medicine). The Respondent presented the following
witnesses: Orion Carr, M.D. (accepted as an expert in the area of family medicine); Frederick Pullen, M.D. (accepted as an expert in the area of otolaryngology and general medicine); Chason Hayes, M.D. (accepted as an expert in urology and general medicine); George Daviglus, M.D. (accepted as an expert in the field of medicine); and Ira S. Jacobson, M.D. (accepted as an expert in the area of family practice). The parties have submitted post-hearing proposed findings of fact. A ruling has been made on each proposed finding of fact in the Appendix to this order.
FINDINGS OF FACT
Based upon my observation of the witnesses and their demeanor while testifying, the documentary evidence received and the entire record compiled herein, I hereby make the following findings of fact:
The Respondent, Zevart Manoyian, M.D. is a licensed physician in the State of Florida, having been issued License No. ME 0003347. Respondent is engaged in the practice of family medicine at 725 Opa Locke Boulevard, Opa Locke, Florida. The Respondent has practiced medicine for the past thirty-eight years.
The Respondent treated patient Willie Dawson from October 1981 through May 1984. When interviewed by DPR Investigator Lichtenstein during the initial investigation of this case on October 2, 1986, the Respondent stated that she was treating Dawson for a broken jaw and depression.
Based on information contained in hospital records and the Respondent's office records during the period which Dawson was treated by Respondent, the following medical history is disclosed:
In 1980, Dawson was hospitalized because of a broken jaw;
In 1982, the Respondent diagnosed Dawson as having narcolepsy and began prescribing Preludin.
In 1984, Dawson was admitted to the Veteran's Administration Hospital and died due to an "intestinal obstruction."
Between December 1983 and September 1984, the Respondent prescribed 180 doses of Preludin and 180 doses of Percodan to Dawson.
Narcolepsy is a rare and unusual sleeping disorder and may be treated with Preludin, a Schedule II controlled drug.
Percodan, a Schedule II controlled drug, may be prescribed for pain. Percodan could be an appropriate medication to prescribe for lingering pain associated with a previously broken jaw.
The Respondent's medical records pertaining to Dawson contained no medical history, given by the patient, allergy history physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x- rays.
The Physicians' Desk Reference (PDR) is accepted by physicians as an authoritative reference source of appropriate drug usage indications and contraindications, The PDR is made up of inserts provided by various drug companies and manufacturers and will indicate the limits and limitations of a
particular drug. Although the POP is accepted by physicians as an authoritative reference source, physicians recognize that it is merely a guide and that the treating physician must determine the most appropriate and medically justifiable treatment for a given patient.
According to the PDR, the appropriate recommended dosage for Percodan is four per day or one every six hours when medically indicated. However, a physician may increase this dosage if the patient has developed a tolerance to the analgesic effects of the drug or when there is severe pain. The appropriate recommended dosage for Preludin is one per day. The PDR advises that the recommended dosage for Preludin not be exceeded.
The amounts of Preludin and Percodan given to Dawson were within the dosage and administration recommendations in the PDR. In addition, the choice of drug, and the amount prescribed, could have been indicated to a reasonably prudent physician based on Dawson's medical conditions.
The Respondent treated patient Barbara Gaskill from September 1977 through December 1984. When questioned by DPR Investigator Lichtenstein regarding this patient, the Respondent stated that she was treating Gaskill for lower back pain and obesity.
Based on information contained in the Respondent's office records during the period which Gaskill was treated by Respondent, the following medical history is disclosed:
In 1977, Gaskill hurt her back, suffered an arthritis attack and had a ruptured sciatica;
In 1978, Gaskill was experiencing problems sleeping due to her back conditions;
In 1980, Gaskill was involved in an automobile accident;
In 1982, Gaskill suffered headaches;
In March 1983, Gaskill had an infected tooth in her right jaw;
In March 1984, Gaskill injured her back when she tripped and fell;
In April 1984, Gaskill suffered from chronic pain in her lower
back;
Between December 9, 1983, and August 7, 1984, the Respondent prescribed 115 tablets of Tuinal and 102 tablets of Percodan to Gaskill.
Tuinal is a Schedule II controlled drug used to help induce sleep. The recommended dosage in the PDR for Tuinal is one per day.
Tuinal and Percodan, in the amounts prescribed, could be appropriate drugs with which to treat pain and sleeping problems arising from medical problems such as those with which Gaskill suffered between December 9, 1983 and August 7, 1984.
The dosages of Percodan and Tuinal which Respondent prescribed to Gaskill were within the recommended limitations established for those drugs in the PDR.
The Respondent's medical records pertaining to Gaskill contained no medical history given by the patient, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x- rays.
The Respondent treated Linda Godfrey from November 1980 through July 1984. When questioned by DPR Investigator Lichtenstein regarding this patient, the Respondent stated that she was treating Gaskill for severe pain. The Respondent stated she knew that Godfrey was addicted to the medication but that she continued to prescribe the medication to alleviate the pain.
Based on information contained in hospital records and the Respondent's office records during the period Godfrey was treated by Respondent, the following medical history is disclosed:
In 1980, Godfrey was diagnosed as having congenital cerebral palsy and multiple sclerosis. On the same visit, the Respondent noticed that Godfrey had an abscess on her left buttock;
In March of 1981, Godfrey was involved in an automobile accident;
In August of 1981, Godfrey passed a kidney stone and went to the
hospital;
In August and September of 1983, Respondent noted that Godfrey was
experiencing severe pain "all over";
In April of 1984 Godfrey had an infected ulcer;
In June of 1984, Godfrey was admitted to the hospital by the Respondent. The Respondent noted that the patient had a drug addiction, which the patient denied. During Godfrey's hospital stay, the Respondent did not allow her to have visitors because Godfrey was overheard requesting a friend to bring drugs to her in the hospital. Godfrey admitted to snorting cocaine while in the hospital. On June 4, 1984, Godfrey was discharged to North Miami General Hospital in order to be cared for in the drug and detoxification unit. The diagnosis at that time was acute gastritis and drug dependence. On June 3, 1984, the Respondent noted that Godfrey was scheduled for a psychiatric consultation with another physician;
In July of 1984, Godfrey was readmitted to the hospital because she fell down a flight of steps and injured her right knee and twisted her lower back.
Between December 26, 1983, and July 8, 1984, the Respondent prescribed
10 doses of Percocet, 12 doses of Nembutal, and 377 doses of Perdocan to Godfrey.
Percocet is a Schedule II controlled drug which is used in the treatment of pain. Percodan and Percocet are similar except that Percocet has a Tylenol base and Percodan has an aspirin derivative. The PDR's recommended dosages and limitations are the same for Percodan and Percocet.
Nembutal is a short-acting or medium-acting barbiturate and is used to help induce sleep. The recommended dosage in the PDR for Nembutal is one per day.
Percodan, Prococet and Nembutal, in the amounts prescribed, could be appropriate drugs with which to treat pain and associated sleeping problems arising from medical conditions such as those with which Godfrey suffered between December 26, 1983 and July 8, 1984.
The dosages of Percodan, Prococet and Nembutal which Respondent prescribed to Godfrey were within the recommended limitations established for those drugs in the PDR.
Respondent's medical records pertaining to Godfrey contain no medical history given by the patient, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient Martha Guc from January of 1977 through September of 1984. When questioned by DPR Investigator Lichtenstein regarding her treatment of this patient, the Respondent stated that she was treating Guc for severe back pain.
Based on information contained in hospital records and the Respondent's office records during the period which Guc was treated by Respondent, the following medical history is disclosed:
In January of 1979 Guc was involved in a serious automobile accident and also suffered from scoliosis. Guc was experiencing cramps in her spine and was unable to sleep as a result of her back pain;
In the automobile accident of January 1979, Guc received extensive injuries, including multiple abrasions and lacerations, a broken arm and multiple contusions in her sternum and knee. Plastic surgery was required to repair the facial lacerations and her arm was placed in a cast.
In December of 1979, Guc experienced pain in her back and left
knee;
In 1980, Guc continued to experience back pain;
In 1983, Guc was involved in an automobile accident and her head
hit the windshield;
From March to June 1984, Guc continued to experience back pain;
Between January 20, 1984, and August 27, 1984, the Respondent prescribed 580 doses of Percodan to Guc.
Percodan, in the amount prescribed, could be an appropriate drug with which to treat pain arising from medical problems and conditions such as those with which Guc suffered between January 20, 1984 and August 27, 1984.
The dosages of Percodan which Respondent prescribed to Guc were within the recommended limitations established for that drug in the PDR.
The Respondent's medical records pertaining to Guc did not show any medical history, allergy history, physical examination or the results thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient Delores Jones from January of 1969 through October of 1984. When questioned by DPR Investigator Lichtenstein regarding this patient, the Respondent stated that she was treating Jones for back pain. The Respondent stated that she knew that Jones was addicted to narcotics but that the medication was required to relieve the symptoms of pain.
Based on information contained in hospital records and the Respondent's office records during the periods which Jones was treated by Respondent, the following medical history is disclosed:
In 1969, Jones experienced severe back pain;
In 1970, Jones suffered from acute gastritis;
In 1974, Jones again experienced severe back pain;
In May of 1974, Jones was involved in an automobile accident and injured her back;
Additionally, Jones suffered from a hernia, stenosis of the spine and a duodenal ulcer.
Between December 1, 1983, and August 28, 1984, the Respondent prescribed 1200 doses of Percocet to Jones.
The Respondent was aware that Jones was becoming addicted to narcotics and referred Jones to a Doctor Baldry in Coral Gables for treatment. The Respondent stated that she was not aware if Jones ever followed her referral.
Percocet, in the amount prescribed, could be an appropriate drug with which to treat pain associated with medical problems such as those with which Jones suffered between December 1, 1983 and August 28, 1984. The dosages of Percocet which Respondent prescribed to Jones were within the recommended limitations established for that drug in the PDR.
The Respondent's medical records pertaining to Jones did not show any medical history, allergy history, physical examinations or the result thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient Cheryl LeBlanc from December of 1983 through October of 1984. When questioned by DPR Investigator Lichtenstein regarding her treatment of this patient, the Respondent stated that Ms. LeBlanc was being treated for pains in the left hip and bursitis.
Based on information contained in hospital records and the Respondent's office records during the period in which LeBlanc was treated by Respondent, the following medical history is disclosed:
In December of 1983, LeBlanc was diagnosed as having bursitis. Respondent noted that LeBlanc had pains in her left hip and down the posterior portion of her left leg;
On January 6, 1984, the Respondent noted that LeBlanc had bursitis in the left hip;
In July of 1984, Respondent noted that LeBlanc had a problem with a lymph node;
In September of 1984, the Respondent noted that LeBlanc suffered from chronic pain;
(f) Prior to being treated by the Respondent, LeBlanc was admitted to North Shore Medical Center in October of 1983 for treatment of infertility and irregular periods. In October of 1983, LeBlanc had a D&C and salpingogram. In November of 1983, she was readmitted to North Shore Medical Center for tubal reconstruction.
Between December 13, 1983, and August 2, 1984, the Respondent prescribed 90 doses of Percodan to LeBlanc.
Percodan, in the amount prescribed, could be an appropriate drug with which to treat pain arising from medical problems such as those with which LeBlanc suffered between December 13, 1983 and August 2, 1984. The dosages of Percodan which Respondent prescribed to LeBlanc were within the recommended limitations established in the PDR.
Respondent's medical records pertaining to LeBlanc did not show any patient medical history, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient Gerald LeBlanc, husband of Cheryl LeBlanc, from October of 1983 to October of 1984. When questioned by DPR Investigator Lichtenstein regarding this patient, the Respondent stated that Mr. LeBlanc suffered from severe bursitis in the shoulder and upper back pain.
Based on information contained in the Respondent's office records during the period in which LeBlanc was treated by Respondent, the following medical history is disclosed:
On October 7, 1983, LeBlanc was treated for muscle spasms in his
back; shoulder;
On November 9, 1983, LeBlanc was treated for acute bursitis in his
On December 6, 1983, Respondent noted that she intended to wait
one month and if LeBlanc's shoulder was not better, she was going to have it x- rayed;
On December 26, 1983, Respondent noted that LeBlanc's shoulder was still very sore and that he had difficulty working in the cold;
On February 17, 1984, the Respondent noted that LeBlanc still had bursitis in his left shoulder;
On March 16, 1984, the Respondent indicated that LeBlanc still had
bursitis;
On April 25, 1984, and September 17, 1984, Respondent noted that
LeBlanc was still experiencing severe pain in his shoulder;
On October 8, 1984, Respondent noted that LeBlanc refused Tylenol #3, because he stated that it made him sick and nauseous.
Between December 1983 to July 9, 1984, the Respondent prescribed 405 doses of Percodan to LeBlanc.
Percodan, in the amount prescribed, could be an appropriate drug with which to treat pain associated with medical problems such as those with which LeBlanc suffered between December 1983 and July 9, 1984. The dosages of Percodan which Respondent prescribed to LeBlanc were within the recommended limitations established for those drugs in the PDR.
Respondent's medical records pertaining to LeBlanc did not show any medical history, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient Betty Mitchell from November of 1981 to August of 1984. When questioned. By DPR Investigator Lichtenstein regarding this patient, Respondent stated that Mitchell suffered from chronic pain. The Respondent stated that Mitchell was drug dependent, but not addicted.
Based on the information contained in the Respondent's office records during the period in which Mitchell was treated by Respondent, the following medical history is disclosed:
In 1982, Mitchell was shot in her left buttock;
On July 21, 1982, Respondent noted that the bullet was still lodged in Mitchell's buttock and that Mitchell had a drainage tube in her abdomen;
pain;
On September 7, 1982, Mitchell suffered from pelvis and mouth
On January 14, 1983, the Respondent noted that Mitchell suffered
from pain in the buttocks and back;
On April 6, 1984, Respondent noted that Mitchell had pain in her back near her buttock area;
On August 7, 1984, Respondent noted that Mitchell was still experiencing back pain;
On April 18, 1983, Respondent noted that Mitchell was experiencing
pain.
Between December 23, 1983, and August 24, 1984, Respondent prescribed
180 doses of Percodan to Mitchell.
Respondent was aware that Mitchell was becoming dependent on Percodan.
Percodan, in the amount prescribed, could be an appropriate drug with which to treat pain associated with medical problems such as those with which Mitchell suffered between December 23, 1983 and August 24, 1984.
The dosages of Percodan which Respondent prescribed to Mitchell were within the recommended limitations established for that drug in the PDR.
Respondent treated patient Rhona Molin from September of 1981 to October of 1984. When questioned by Investigator Lichtenstein regarding this patient, the Respondent stated that Molin was being treated "for nervousness and being very high strung."
Based on information contained in the Respondent's office records during the period which Molin was treated by Respondent, the following medical history is disclosed:
In 1981, Molin suffered from colitis and stomach pain;
In 1981, Respondent noted that Molin had bursitis in her right
shoulder;
In 1982, Molin suffered from right arm pain;
On March 16, 1984, Respondent noted sporadic stomach pain;
On June 1, 1984, Respondent noted that Molin was nervous and
experiencing severe stomach pain;
On August 28, 1984, Respondent diagnosed Molin as having colitis.
Between December 21, 1983 and August 28, 1984, the Respondent prescribed 300 doses of Tuinal to Molin.
Tuinal, in the amount prescribed, could be an appropriate drug with which to treat sleeping problems arising from the medical conditions with which Molin suffered between December 1983 and August 1984. The dosages of Tuinal which Respondent prescribed to Molin were within the recommended limitations established in the PDR.
The Respondent's medical records pertaining to Molin do not show any patient medical history, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient John Skilles from May of 1981 through October of 1984. When questioned by Investigator Lichtenstein regarding this patient, the Respondent stated that Skilles was being treated for severe pain and bursitis in both shoulders. The Respondent further stated that Skilles was provided two prescriptions for fifty (50) doses of Percodan on the same date because he could not afford to have a prescription for one hundred (100) Percodan filled at one time.
Based on information contained in hospital records and the Respondent's office records during the period in which Skilles was treated by Respondent, the following medical history is disclosed:
Respondent noted on May 25, 1981, that Skilles was shot five or six times in an accident at Camp Pendelton while he was in the military. Respondent noted that his upper body was full of lead shot;
On September 14, 1981, the Respondent noted that Skilles was experiencing pain in both shoulders;
On December 7, 1981, the Respondent indicated that Skilles was still experiencing shoulder pain;
On August 30, 1982, Respondent noted that Skilles was in an automobile accident and injured the left side of his chest;
On October 1, 1982, Respondent noted that Skilles was still experiencing shoulder and chest pain;
On June 3, 1983, the Respondent noted that Skilles had pain in both shoulders and was unable to work (Skilles was a painter);
On September 6, 1983, the Respondent noted that Skilles was experiencing severe pain in his shoulder. On December 28, 1983, Respondent noted chest pain, and on February 17, 1984, and March 26, 1984, it was noted that Skilles was still experiencing chest pain;
On June 13, 1984, the Respondent noted that Skilles had bursitis in both shoulders and was suffering from insomnia;
On October 1, 1984, the Respondent noted that Skilles suffered from severe pain in the shoulder and chest.
Between August 11, 1983, and September 1, 1984, the Respondent prescribed 90 doses of Tuinal and 600 doses of Percodan to Skilles.
Tuinal and Percodan, in the amounts prescribed, could be appropriate drugs with which to treat pain and sleeping problems arising from medical conditions such as those with which Skilles suffered between August 1983 and September 1984.
Respondent's medical records pertaining to Skilles do not show any medical history, allergy history, physical examinations or the results thereof, laboratory tests or the results thereof, or x-rays.
The Respondent treated patient June Sweeney between February of 1980 and August of 1984. When questioned by Investigator Lichtenstein regarding this patient, Respondent stated that she was treating Sweeney for nervousness and insomnia.
Based on information contained in Respondent's office records during the period in which Sweeney was treated by Respondent, the following medical history is disclosed:
In 1980, Sweeney was having difficulty sleeping and was experiencing back pain;
In 1982, Sweeney was involved in an automobile accident and experienced more back pain;
In 1982, Sweeney experienced severe back pain.
In August of 1984 Sweeney returned to Respondent's office complaining of pain and insomnia.
On August 9, 1984, the Respondent prescribed 30 doses of Percodan and
30 doses of Tuinal to Sweeney.
Percodan and Tuinal, in the amounts prescribed, could be appropriate drugs with which to treat pain and sleeping problems arising from medical conditions such as those with which Sweeney suffered.
The dosages and Percodan and Tuinal which Respondent prescribed to Sweeney were within the recommended limitations as established for those drugs in the PDR.
The Respondent's medical records pertaining to Sweeney did not show any patient medical history, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, and no x-rays.
The Respondent treated patient Mike Sweeney from April of 1979 to October of 1984. When questioned by Investigator Lichtenstein regarding this patient, Respondent stated that she was treating Mr. Sweeney for "various things, including back pain and insomnia."
Based on information contained in hospital records and the Respondent's office records during the period in which Sweeney was treated by the Respondent, the following medical history is disclosed:
Prior to being seen by Respondent, Sweeney had surgery on his left buttock in 1978. On March 12, 1979, Sweeney fell and injured his back;
In May of 1979, Sweeney was beaten up and his left eye was
swollen;
In 1980, the Respondent noted that Sweeney was still experiencing
back pain;
On May 11, 1981, the Respondent noted that Sweeney was still experiencing back pain and was experiencing difficulty sleeping as well;
On August 4, 1981, Respondent again noted that Sweeney was still experiencing back pain;
Between December 1983 and September 1984, Respondent prescribed 240 doses of Tuinal and 48 doses of Percodan to Mike Sweeney. On one occasion, the Respondent prescribed two thirty-dose prescriptions of Percodan to Sweeney on the same day. The Respondent stated that it was cheaper to prescribe multiple prescriptions of thirty doses than one prescription for sixty.
Tuinal and Percodan, in the amounts prescribed could be appropriate drugs with which to treat pain and sleeping problems associated with medical conditions such as those with which Mike Sweeney suffered between December 1983 and September 1984.
The dosages of Percodan and Tuinal which Respondent prescribed to Sweeney were within the recommended limitations established for those drugs in the PDR.
The Respondent treated patient Ivan Weithorn from November of 1970 through September of 1984. When questioned by Investigator Lichtenstein regarding this patient, the Respondent stated that she treated Weithorn for back and shoulder pain and insomnia.
Based on information contained in the Respondent's office records during the period in which Weithorn was treated by Respondent, the following medical history is disclosed:
In 1977, Respondent recorded that Weithorn had dental work done and a root Canal was done along with oral surgery;
In 1978, Respondent noted that Weithorn had pain in his right
elbow;
In 1982, the Respondent noted that Weithorn fell and hit a table;
In August 1983, the Respondent noted that Weithorn had an abscess
on his left forearm and in December 1983 noted that he had an infected finger on his left hand;
On February 3, 1984, Respondent noted that the patient had sustained a puncture wound in his upper lip.
Between December 9, 1983, and August 27, 1984, the Respondent prescribed 360 doses of Tuinal and 600 doses of Percodan to Weithorn.
Tuinal and Percodan, in the amounts prescribed, could be appropriate drugs with which to treat pain and sleeping problems arising from medical conditions such as those with which Weithorn suffered between December 1983 and August 1984.
The dosages of Percodan which Respondent prescribed to Weithorn were within the recommended limitations established for that drug in the PDR. The dosages of Tunial which Respondent prescribed to Weithorn slightly exceeded the recommended dosage contained in the PDR. The FOR recommends one Tuinal per day. In this instance, 360 Tuinal were prescribed over a 300-day period. It may be appropriate for a physician in the exercise of his or her professional judgment, to slightly exceed the recommended dosage of a particular drug if the patient has developed a tolerance to the effects of the substance.
Respondent's medical records pertaining to Weithorn do not show any patient medical history, allergy history, physical examinations or the results thereof, laboratory tests ordered or the results thereof, or x-rays.
All of the Respondent's medical records were stored in a plastic shoe- box like container and were maintained on 3 X 5 index cards.
The use of small file-type index cards for the maintenance of a physician's office medical records was prevalent about 20 to 25 years ago. Today, most physician's written medical records are maintained in standard size folders and include laboratory tests, examination results, hospital records, discharge summaries and letters from consulting physicians.
Although Respondent sometimes indicated a diagnosis on an initial visit, she rarely noted the diagnosis, objective findings or subjective symptoms of the patients on return visits. On some occasions, a subjective complaint such as "pain" was the only symptom recorded.
Extensively within the Respondent's medical records upon a return visit of a patient, nothing was recorded except a prescription, the number of doses and the office charge. Occasionally, a blood pressure or temperature
reading was recorded by Respondent. Except for the prescription of pain and sleep-inducing medication, the Respondent's written medical records for the patients described herein failed to demonstrate or indicate the Respondent's overall treatment plan for the patients.
In order to justify a course of medical treatment which includes the long term use of Schedule II controlled substances, good medical practice requires that a physician's written patient medical records contain subjective findings (i.e. complaint, onset, duration and severity), a patient history and objective, physical findings made by the physician and/or confirmed and disclosed through laboratory tests or x-rays.
The medical records maintained by Respondent on the patients described herein contained only anecdotal information about the patients and contained only scant subjective and objective findings, contained no medical histories and no laboratory results or x-rays. The records maintained by Respondent during the periods when Schedule II controlled drugs were prescribed to the patients herein were inadequate and demonstrated a failure to provide medical care at the minimum level of skill and care required of a reasonably prudent physician under similar conditions.
Episodic treatment or care is defined as treatment of symptoms or problems as they present themselves in a patient without any consideration of the root causes of the symptoms, the long term affects the problem may have on the patient, and no consideration of a viable treatment plan. Episodic treatment is considered very poor quality medical care and is a type of treatment which is below the standard of care which is recognized by reasonably prudent physicians as being acceptable. This type of treatment is especially unacceptable when provided to a patient on a long term basis.
The patients described herein had medical conditions which could have caused moderate to moderately severe pain and/or sleep disorders. Moderate to moderately severe pain may be defined as pain that interferes with a person's ability to lead a normal life and to perform the daily activities of living which they would normally perform. Chronic pain patients present a difficult challenge to the treating physician because pain is not usually a directly measurable disability. Some patients require greater or lesser amounts of pain medication to relieve a similar amount of pain than do other patients. It may be appropriate and ethical for a physician to prescribe a Schedule II controlled drug to relieve a patient's pain even though the patient may have developed a tolerance to or dependence on the substance.
In each instance described herein, the Respondent prescribed the medication in question in a good faith effort to either relieve pain or induce sleep in the patients that she was treating. There was no evidence that any of the drugs prescribed to the patients discussed herein were ever resold on the streets or used by anyone other than the patients for whom they were prescribed.
Doctors Handwerker and Frazier testified on behalf of the Petitioner. Neither Dr. Handwerker nor Dr. Frazier examined any of the fifteen patients described herein nor had they reviewed or seen any of the patient hospital records.
The Respondent has privileges at the North Shore Hospital in Miami and enjoys an excellent reputation among her fellow physicians as a person of good character and as a dedicated provider of medical treatment. In addition, the Respondent is known among her colleagues as a physician that devotes a substantial portion of her time treating indigent patients.
The Respondent cooperated fully with DPR Investigator Lichtenstein during the initial investigation of this case.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of this proceeding. See Section 120.57(1), Florida Statutes.
The Board of Medical Examiners is empowered to revoke or suspend the license of, or otherwise discipline, any physician who violates any of the following provisions of Section 458.331(1), Florida Statutes:
* * *
(n) Failing to keep written medical records justifying the course of treatment for the patient, including, but not limited to, patient histories, examination results, and test results.
* * *
(q) Prescribing, dispensing, administering, mixing, or otherwise preparing a legend drug, including any controlled substance, other than in the course of the physician's professional practice. For the purposes of this paragraph, it shall be legally presumed that prescribing, dispensing, administering, mixing, or otherwise preparing legend drugs, including all controlled substances, in-
appropriately or in excessive or inappropriate quantities is not in the best interest of the patient and is not in the course of the physician's professional practice, without regard to his intent.
* * *
(t) Gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances.
The Petitioner has the burden of proof in this license discipline case and must prove clearly and convincingly that the alleged violations of the
above-cited statutory provisions occurred. Bowling vs. Department of Insurance,
394 So.2d 165 (Fla. 1st DCA 1981); Robinson vs. Florida Board of Dentistry 447 So.2d 930 (Fla. 3rd DCA 1984); and Sneij vs. Department of Professional Regulation, 454 So.2d 795 (Fla. 3rd DCA 1984).
Count I of the Administrative Complaint alleges that the Respondent violated Section 458.331(1)(q), Florida Statutes, by prescribing controlled
substances other than in the course of her professional practice. The Complaint specifically alleged that the Respondent violated this section by prescribing excessive quantities of Schedule II controlled substances to the patients as described in the Findings of Fact herein. The Petitioner failed to carry its burden of proof regarding the allegations of Count I of the Administrative Complaint. All of the patients previously mentioned were treated by Respondent with appropriate schedule II medication in quantities which could have been indicated by their medical conditions. There was no evidence that the patients were not suffering from significant pathologies which would require such medication. On many occasions the patient's medical condition was corroborated by hospital records. In this regard, the testimony of the Respondent's experts indicating that the particular medications prescribed were appropriate and not excessive for the pathologies indicated was more persuasive than that of the Petitioner's experts. The Respondent is not guilty of Count I.
Count II of the Administrative Complaint charges the Respondent with a violation of Section 4SS.331(1)(n), Florida Statutes. That Section provides that disciplinary action may be taken against the physician for:
"Failing to keep written medical records justifying the course of treatment of the patients, including, but not limited
to, patient histories, examination results, and test results."
The Petitioner has shown by clear and convincing evidence that the Respondent failed to keep written medical records justifying the course of treatment of her patients. The medical records maintained by the Respondent on the patients listed contained only anecdotal information about the patients, but did not contain any patient histories, examination results, test results or other pertinent information. A physician's written patient medical records should contain patient histories, physical examination results, laboratory test results and other pertinent information, especially when the course of treatment includes the prescribing of Schedule II controlled substances. Good medical practice would require that a physician's treatment plan for a particular patient be included in, and discernible upon review of, the patient's written medical records. Although the significant medical conditions of some of Respondent's patients were documented by hospital records, the Respondent failed to maintain adequate written patient medication records of her own justifying the course of treatment of her patients.
Count III of the Administrative Complaint charges that the Respondent violated Section 458.331(1)(t), Florida Statutes, by:
"Committing gross or repeated malpractice or the failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances."
The Petitioner established by clear and convincing evidence that the Respondent's failure to keep adequate written medical records concerning Ker patients amounted to a failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. While the particular drugs prescribed by the Respondent were not shown to be
inappropriate or excessive for the patients concerned, the Respondent's written medical records were inadequate to demonstrate her overall treatment plans for the patients. A physician's medical records must demonstrate his or her attempt to understand the base line of the patients medical condition by x-rays, physical examinations, history or laboratory work-ups. The Respondent's patient medical records demonstrated no more than "episodic treatment". Medical records which fail to justify the course of treatment of the patient and which demonstrate no more than episodic treatment (especially when long term patients are involved), demonstrates a failure to practice medicine with that level of care skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances.
Respondent is guilty of Count III of the Administrative Complaint as described herein.
Based on the foregoing Findings of Fact and Conclusions of Law and a consideration of the aggravating and mitigating factors delineated in Rule 21M- 20.01, F.A.C. it is,
RECOMMENDED that a Final Order be entered assessing a $2,000 administrative fine. It is further recommended that Respondent's license to practice medicine in the State of Florida be placed on probation for a period of three (3) years under the following terms and conditions:
Respondent shall make semi-annual appearances before the board.
Respondent shall not use, dispense, administer, or prescribe Schedule II controlled substances, except in a hospital setting.
Respondent shall successfully complete fifty (50) hours annually of Category I Continuing Medical Education. The primary subject matter of each course taken must involve Pharmacology, General Medicine and/or Medical Record- Keeping.
DONE and ORDERED this 17th day of December, 1986 in Tallahassee, Leon County, Florida.
W. MATTHEW STEVENSON Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 17th day of December, 1986.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 86-0995
The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case.
Rulings on Proposed Findings of Fact Submitted by the Petitioner
Adopted in Finding of Fact 1.
Rejected as subordinate.
Rejected as subordinate.
Rejected as subordinate.
Rejected as subordinate.
Partially adopted in Findings of Fact 2, 3 and 8.
Matters not contained therein are rejected as subordinate and/or unnecessary.
Rejected as unnecessary.
At the final hearing, the Petitioner was allowed to amend the Administrative Complaint to reflect that Mary Dukes received zero (0) doses of Percodan. Thus, any findings regarding the prescribing of Percodan to patient Mary Dukes is unnecessary.
Adopted in Findings of Fact 11 and 13.
Adopted in Findings of Fact 18 and 20.
Rejected as subordinate.
Adopted in Finding of Fact 26.
Adopted in Finding of Fact 26.
Adopted in Finding of Fact 34.
Adopted in Findings of Fact 32 and 35.
Adopted in Findings of Fact 38 and 40.
Adopted in Findings of Fact 43 and 45.
Adopted in Findings of Fact 47 and 49.
Adopted in Findings of Fact 53 and 55.
At the final hearing the Petitioner was allowed to amend the complaint to reflect that zero (0) doses of Percodan were prescribed to patient James Sams. The Petitioner stated that it was determined by Investigator Lichtenstein after viewing the signature of the Respondent and those upon the prescriptions acquired from the various pharmacies that all
prescriptions for patient Sams were forgeries. There- fore, Findings of Fact involving prescriptions to patient James Sams are unnecessary.
Partially adopted in Findings of Fact 58 and 60. Matters not contained therein are rejected as unnecessary.
Adopted in Findings of Fact 63 and 65.
Adopted in Findings of Fact 69 and 71.
Adopted in Findings of Fact 74 and 76.
Rejected as subordinate and unnecessary.
Adopted in Finding of Fact 83.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Addressed in the Procedural Background section.
Rejected as a recitation of testimony.
Rejected as subordinate and/or unnecessary.
Rejected as subordinate and/or unnecessary.
Adopted in Finding of Fact 84.
Partially adopted in Finding of Fact 7. Matters not contained therein are rejected as subordinate and/or a recitation of testimony.
Rejected as a recitation of testimony.
Partially adopted in Finding of Fact 83. Matters not contained therein are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Adopted in Finding of Fact 85.
Adopted in Finding of Fact 85.
Rejected as a recitation of testimony.
Adopted in Finding of Fact 86.
Adopted in Findings of Fact 85 and 86.
Rejected as a recitation of testimony.
Addressed in Procedural Background section.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Adopted in Finding of Fact 82.
Addressed in Procedural Background section.
Partially adopted in Finding of Fact 86. Matters not contained therein are rejected as subordinate.
Partially adopted in Finding of Fact 82. Matters not contained therein are rejected as subordinate.
Rejected as a recitation of testimony.
Adopted in Finding of Fact 86.
Rejected as a recitation of testimony.
Addressed in Procedural Background section.
Rejected as a recitation of testimony.
Addressed in Procedural Background section.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Adopted in Finding of Fact 86.
Rejected as a recitation of testimony.
Partially adopted in Findings of Fact 7 and 8. Matters not contained therein are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially adopted in Finding of Fact 9. Matters not contained therein are rejected as a recitation of testimony.
Rejected as subordinate and unnecessary.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony and/or subordinate.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially adopted in Finding of Fact 37. Matters not contained therein are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially adopted in Finding of Fact 86. Matters not contained therein are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially adopted in Finding of Fact 86. Matters not contained therein are rejected as a recitation of testimony.
Partially adopted in Finding of Fact 86. Matters not contained therein are rejected as a recitation of testimony.
Adopted in Findings of Fact 68 and 86.
Rejected as a recitation of testimony.
Partially adopted in Findings of Fact 79 and
86. Matters not contained therein are rejected as a recitation of testimony.
Partially adopted in Findings of Fact 85 and 86.
Matters not contained therein are rejected as a recitation of testimony.
Adopted in Finding of Fact 85.
Adopted in Finding of Fact 86.
Rulings on Proposed Findings of Fact Submitted by the Respondent
(The Respondent's Findings of Fact were un-numbered. For the purpose of this Appendix, each paragraph in the Findings of Fact submitted by the Respondent was assigned a number in chronological order beginning with Paragraph Number 1.)
Adopted in Finding of Fact 1.
Addressed in Conclusions of Law Section.
Addressed in Procedural Background section.
Partially adopted in Findings of Fact 9 and 87. Matters not contained therein are rejected as not supported by the weight of the evidence.
Rejected as argument end/or subordinate.
Rejected as argument and/or subordinate.
Adopted in substance in Findings of Fact 2, 3, 4, 5, 6, 8, 9 and 10.
Rejected as unnecessary.
Adopted in substance in Findings of Fact 11, 12, 13, 14, 15 and 16.
Adopted in substance in Findings of Fact 18, 19, 20, 21, 22, 23 and 24.
Adopted in Finding of Fact 19.
Adopted in Finding of Fact 19.
Adopted in substance in Findings of Fact 20, 21, 22,
23 and 24.
Adopted in substance in Findings of Fact 26 and 27.
Adopted in Finding of Fact 27.
Adopted in substance in Findings of Fact 27, 28, 29
and 30.
Adopted in substance in Findings of Fact 32 and 33.
Adopted in substance in Findings of Fact 34, 35 and 36.
Adopted in substance in Findings of Fact 38 and 39.
Adopted in substance in Finding of Fact 39.
Partially adopted in Findings of Fact 40 and 41. Matters not contained therein are rejected as misleading.
Adopted in substance in Findings of Fact 43 and 44.
Adopted in substance in Finding of Fact 44.
Partially adopted in Finding of Fact 46. Matters not contained therein are rejected as misleading.
Adopted in substance in Findings of Fact 47 and 48.
Adopted in substance in Finding of Fact 48.
Partially adopted in Findings of Fact 49, 51 and 52. Matters not contained therein are rejected as mis- leading.
Adopted in substance in Findings of Fact 53 and 54.
Partially adopted in Findings of Fact 55 and 56. Matters not contained therein are rejected as mis- leading.
Rejected as unnecessary.
Rejected as unnecessary.
Adopted in substance in Findings of Fact 58 and 59.
Adopted in substance in Finding of Fact 59.
Adopted in substance in Findings of Fact 60 and 61.
Adopted in substance in Findings of Fact 63
and 64. 36. Adopted in substance in Findings of Fact 65,
66 and 67.
Adopted in substance in Findings of Fact 69 and 70.
Adopted in substance in Findings of Fact 71, 72 and 73.
Adopted in substance in Findings of Fact 74 and 75.
Adopted in substance in Findings of Fact 76,
77 and 78.
Rejected as a recitation of testimony and/or subordinate.
Rejected as argument.
Rejected as a recitation of testimony.
Rejected as argument.
Adopted in substance in Finding of Fact 88.
Partially addressed in Procedural Background section. Matters not contained therein are rejected as recitation of testimony.
Adopted in Finding of Fact 5. 48. Rejected as a recitation of testimony.
Adopted in substance in Finding of Fact 10.
Adopted in substance in Finding of Fact 16.
Rejected as argument and/or a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as unnecessary.
Rejected as a recitation of testimony.
Partially adopted in Finding of Fact 88. Matters not contained therein are rejected
as a recitation of testimony.
Adopted in substance in Finding of Fact 89.
Partially addressed in Procedural Background section. Matters not contained therein are rejected as subordinate.
Rejected as a recitation of testimony.
Partially adopted in Findings of Fact 6 and
10. Matters not contained therein are rejected as a recitation of testimony.
Adopted in substance in Finding of Fact 5. Matters not contained therein are rejected as a recitation of testimony.
Partially adopted in Finding of Fact 23. Matters not contained therein are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as argument and/or a recitation of testimony.
Partially adopted in Finding of Fact 82. Matters not contained therein are rejected as subordinate.
Addressed in Procedural Background section.
Rejected as subordinate.
Partially adopted in Finding of Fact 87. Matters not contained therein are rejected as a recitation of testimony.
Adopted in substance in Finding of Fact 8.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially addressed in Procedural Background section. Matters not contained therein
are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially addressed in Procedural Background section. Matters not contained therein are rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Rejected as a recitation of testimony.
Partially adopted in Findings of Fact 87
and 88. Matters not contained therein
are rejected as argument and/or a recitation of testimony.
Rejected as argument.
Partially adopted in Finding of Fact 81. Matters not contained therein are rejected as argument.
Partially adopted in Finding of Fact 90. Matters not contained therein are rejected as subordinate.
COPIES FURNISHED:
David F. Bryant, Esquire 1107 E. Jackson Street Suite 104
Tampa, Florida 33602
Michael I. Schwartz, Esquire
119 North Monroe Street Tallahassee, Florida 32301
Fred Roche Secretary
Department of Professional Regulation
130 North Monroe Street Tallahassee, Florida 32301
Wings S. Benton, Esquire General Counsel
Department of Professional Regulation
130 North Monroe Street Tallahassee, Florida 32301
Dorothy Faircloth Executive Director
Department of Professional Regulation
130 North Monroe Street Tallahassee, Florida 32301
=================================================================
AGENCY FINAL ORDER
================================================================= BEFORE THE BOARD OF MEDICINE
DEPARTMENT OF PROFESSIONAL REGULATION,
Petitioner,
vs. | DPR CASE NO. | 0050939 |
DOAH CASE NO. | 86-0995 | |
ZEVART MANOYIAN, | LICENSE NO. | ME 0003347 |
Respondent.
/
FINAL ORDER
This cause came before the Board of Medicine (Board) pursuant to Section 120.57(1)(b)(9), Florida Statutes, on February 7, 1987, in Jacksonville, Florida for the purpose of considering the hearing officer's Recommended Order (a copy of which is attached hereto) in the above-styled cause. Petitioner, Department of Professional Regulation, was represented by Bruce D. Lamb, Esquire.
Respondent was present and represented by Michael I. Schwartz, Esquire. At the hearing before the Board, the parties made an oral agreement with regard to the conclusions of law and the penalty to be imposed by the Board. The Respondent agreed not to appeal the Board's action if the Board accepted the oral agreement of the parties. The Board did accept the oral agreement, which agreement is reflected below.
Upon review of the recommended order, the argument of the parties, the oral agreement of the parties, and after a review of the complete record in this case, the Board makes the following findings and conclusions.
FINDINGS OF FACT
The findings of fact set forth in the Recommended Order are approved and adopted and incorporated herein.
There is competent substantial evidence to support the findings of fact.
CONCLUSIONS OF LAW
The Board has jurisdiction of this matter pursuant to Section 120.57(1), Florida Statutes, and Chapter 458, Florida Statutes.
The conclusions of law set forth in the Recommended Order are approved and adopted and incorporated herein. The Board specifically finds that the violation of Section 458.331(1)(t), Florida Statutes, constituted only the
failure to practice medicine with that level of care, skill, and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances and did not constitute gross or repeated malpractice.
There is competent substantial evidence to support the conclusions of
law.
Upon a complete review of the record in this case, the Board determines
that the penalty recommended by the Hearing Officer be MODIFIED as reflected below. WHEREFORE,
IT IS HEREBY ORDERED AND ADJUDGED that
Respondent's license to practice medicine is REPRIMANDED.
Respondent shall pay an administrative fine in the amount of $2000.00 to the Executive Director within 30 days of the date of this Final Order is filed.
Respondent's license to practice medicine in the State of Florida shall be placed on PROBATION for a period of 3 years subject to the following terms and conditions:
Respondent shall appear before the Board at the first meeting after her probation begins and at the last meeting before her probation ends and at such other times as requested by the Board.
Respondent shall not use, dispense, administer, or prescribe Schedule II controlled substances, except in a hospital setting.
Respondent shall successfully complete fifty (50) hours annually of Category I Continuing Medical Education. The primary subject matter of each course taken must involve Pharmacology, General Medicine and/or Medical Record- Keeping.
If Respondent resides or practices outside the State of Florida continuously for thirty (30) or more days, such time shall not be counted as part of the probationary period. She must immediately notify the Board at the time she leaves the state and when she returns to the state and must keep current residence and business addresses on file with the Board.
Respondent understands that during the course of the probation, quarterly reports shall be prepared by the Investigators with the Department detailing Respondent's compliance with the terms and conditions of this probation. The Department investigation shall include an unannounced quarterly review of her medical records. On the record at the hearing, Respondent waived confidentiality of these reports as to the Department and the Board only so that the Board may review these reports.
Respondent shall submit semi-annual reports, in affidavit form, the contents of which shall be specified by the Board. The reports shall each include:
Brief statement of why he or she is on probation;
Practice location;
Describe current practice (type and composition);
State compliance with probationary terms; and
Advise Board of any problems.
This Order takes effect upon filing.
Pursuant to Section 120.59, Florida Statutes, the parties are hereby notified that they may appeal this final order by filing one copy of a notice of appeal with the clerk of the agency and by filing the filing fee and one copy of a notice of appeal with the District Court of Appeal within thirty days of the date this order is filed, as provided in Chapter 120, Florida Statutes, and the Florida Rules of Appellate Procedure.
DONE AND ORDERED this 24 day of February, 1987.
BOARD OF MEDICINE
JAMES N. BURT, M.D. CHAIRMAN
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing FINAL ORDER has been provided by certified mail to Zevart Manoyian, M.D., 725 Opa-locka Boulevard, Opa-locka, Florida 33054, and Michael I. Schwartz, Esquire, 119 North Monroe Street, Tallahassee, Florida 32301; by U.S. Mail to W. Matthew Stevenson, Hearing Officer, Division of Administrative Hearings, 2009 Apalachee Parkway, Tallahassee, Florida 32302, by regular U.S. Mail to David E. Bryant, Esquire, 1107 East Jackson Street, Suite 104, Tampa, Florida 33602, and by hand delivery to Bruce D. Lamb, Esquire, Department of Professional Regulation, 130 North Monroe Street, Tallahassee, Florida 32301 at 5:00 pm this 24 day of February, 1987.
Dorothy J. Faircloth Executive Director
| Issue Date | Proceedings |
|---|---|
| Dec. 17, 1986 | Recommended Order (hearing held , 2013). CASE CLOSED. |
| Issue Date | Document | Summary |
|---|---|---|
| Feb. 24, 1987 | Agency Final Order | |
| Dec. 17, 1986 | Recommended Order | Doctor's failure to keep adequate written medical records constituted failure to practice medicine within acceptable standards of care. |
DEPARTMENT OF HEALTH, BOARD OF MEDICINE vs ERIC N. GROSCH, M.D., 86-000995 (1986)
BOARD OF MEDICAL EXAMINERS vs. ORLANDO C. RAMOS, 86-000995 (1986)
DEPARTMENT OF HEALTH, BOARD OF MEDICINE vs DONALD A. TOBKIN, M.D., 86-000995 (1986)
DEPARTMENT OF HEALTH, BOARD OF PODIATRIC MEDICINE vs DANIEL DRAPACZ, 86-000995 (1986)
