Your best defence – the importance of good medical records
Introduction
All registered health practitioners are required to comply with medical record keeping requirements. While registered health practitioners are not expected to produce “perfect” records, sufficient information regarding patients must be recorded to permit continuity in the delivery of medical services.
Not only is proper record keeping essential for patient care, accurate, legible, and complete medical records can also assist in the defence of a complaint or claim made against a health practitioner or health organisation.
Legislative framework
The Health Practitioner Regulation National Law (National Law) applies in Tasmania pursuant to section 4 of the Health Practitioner Regulation National Law (Tasmania) Act 2010 (Tas).
The National Law establishes the Australian Health Practitioner Regulation Agency (AHPRA). AHPRA works with the 15 National Boards to help protect the public by regulating Australia’s registered health practitioners. It does this by setting standards and policies that all registered health practitioners must meet.
Relevant codes of conduct
Each of the 15 National Boards have an approved code of conduct or code of ethics that applies to the registered health practitioners they regulate.
For example, for medical practitioners, the relevant code of conduct is: Good medical practice: a code of conduct for doctors in Australia (Code). It is intended to complement the Australian Medical Association Code of Ethics.
The Code describes the professional behaviour and conduct expectations for medical practitioners. It sets out the principles that characterise good medical practice and the standards of ethical and professional conduct expected of doctors by their professional peers and the community.
The standard of professional behaviour with respect to maintaining adequate records is set out in section 10.5 of the Code (Medical records).
Section 10.5 of the Code sets out that maintaining clear and accurate medical records is essential for the continuing good care of patients. Comprehensive medical records are also the best defence to a complaint or claim made about the treatment or care provided to a patient.
What needs to be documented – everything and why!
Health practitioners and health organisations must ensure that all information relevant to diagnosis or treatment is documented in the patient record. This should include the clinical reasoning, such as why a certain diagnosis was reached or excluded, why a test or procedure was performed, examination or investigation results, medication prescribed, as well as the patient’s relevant medical and social history.
It is also important to keep in mind that patients are entitled to access their medical records and therefore it goes without saying that medical records must be objective and show respect for the patient.
The importance of good medical records
Obtaining a copy of the medical records is generally the first step a complainant or their legal representative will take when considering whether to commence proceedings, and who to commence proceedings against. A copy of the relevant medical records is also routinely requested as part of any investigation undertaken by AHPRA, the Office of the Health Complaints Commissioner, Medicare (for billing investigations), and in coronial matters.
Contemporaneous medical records are the simplest evidence for both health practitioners and health organisations in defence of complaints, claims, and coronial investigations. Medical records will usually form the foundation for most responses and defences in these types of proceedings.
For an AHPRA notification, the standard of the medical records can and often is assessed as part of the investigation. This can be the case even where the initial complaint has nothing to do with record keeping. The standard of record keeping is considered as part of the assessment as to whether a practitioner is meeting the requisite standards of medical practice. Inadequate record keeping may result in a practitioner being directed to undergo a performance assessment, or in more severe outcomes to a notification, such as the addition of supervision or audit conditions.
From a claims perspective, inadequate records can affect claim outcomes. Claims are much harder or sometimes cannot be defended because of poor records – if it’s not documented, it didn’t happen!
Practical tips
- Make records at the time of events or as soon as possible afterwards to help ensure your records are accurate and include all necessary information.
- Record information or advice given to a patient, including questions asked by the patient and any information sheets provided. Particularly for informed consent purposes.
- Document all verbal discussions, including telephone conversations, regarding a patient.
- Document all orders as soon as possible. Caution should be exercised around standing orders.
- Ensure that not only positive findings are recorded, but also that any negative history or findings, and differential diagnosis considered, are documented.
- Record all investigations and results in the patient notes.
- Document if peer review has occurred.
- Ensure that medical records are in a form that can be understood by other health practitioners.
- Include the management plan and any other details necessary to facilitate continuity of care.
- Exercise caution around delegating record keeping obligations.
Takeaways
- Good medical practice – as a registered health practitioner, you have a professional obligation to maintain adequate medical records.
- Harm minimisation – proper medical record keeping protects the patient, protects you and protects your organisation.
- Risk management – maintaining clear and accurate medical records is the easiest way to limit your risk exposure.
Do your medical records need a health check?
AHPRA have developed a self-reflective tool on managing health records, accessible here:
Australian Health Practitioner Regulation Agency – Managing health records (ahpra.gov.au)
More information
If you have any questions or would like further information regarding this article, please contact:
| Amy Tremayne Senior Associate T: (03) 6235 5173 E: atremayne@pageseager.com.au |
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| Sara-Jane Knott Senior Associate M: 0417 598 473 E: sknott@pageseager.com.au |
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Published: 20 June 2024
