Patient records should be kept in accordance with the Privacy Act 1988 (Cth) as amended under the Privacy Amendment (Private Sector) Act 2000 and the various State Privacy Acts.
The Act and amendments regulate the use and handling of personal information in private sector organisations including health service providers.
The provisions of the Act and amendments impose obligations on health service providers to ensure personal information is kept secure and private.
The Act also applies the Australian Privacy Principles to health service providers.
Practitioners registered with the Chinese Medicine Board of Australia (CMBA) should also familiarise themselves with the CMBA Guidelines for Patient Records.
Click here to visit the website of the Office of the Australia Information Commissioner.
Patient records must be accurate, up-to-date and complete
Patient records can be kept electronically or hard copy. If records are hand written they should be written clearly in ink (not pencil), in English and be easily read and understood.
Any amendments to a patient's record should not be erased or deleted. A single line should be crossed through information to be amended and the new information recorded alongside the amendment, dated and signed by the practitioner. Errors should not be obliterated.
Entries in patient records should not be made in advance of the consultation.
Patient records should contain adequate information to provide quality care to the patient.
Patient records should contain any diagnostic reports, imaging reports and other reports/data that are used as part of the consultation and treatment process.
The health records of patients are accepted by courts as evidence in a dispute or claim and substantiates the care provided to the patient. It is important that patient records are kept up-to-date and information recorded accurately at all times.
Patient records whether kept electronically or hard copy should be kept confidential and in a secure place at all times.
Patients are entitled to request and receive a copy of their health record.
The practitioner must safeguard all patient records and information from any disclosure except as required by law.
Patient records and information maintained on computers must be kept secure and not be visable to other persons.
Verbal exchange of patient information between healthcare providers and those involved with patient care should occur to ensure timely care to the patient.
Practitioners who exchange verbal information with or about patients should ensure they cannot be overheard by others who are not involved in the patient care or do not have a right to hear the information.
**Patient records should be kept indefinitely as issues and claims regarding a patient can arise many years after consulting with or treating a patient.
The following is provided as a guide on keeping patient records:
- Patient's full name
- Gender (male/female)
- Date of birth
- Phone numbers
- Marital status (single, married, divorced, widowed)
- Consent of parent/guardian, if a minor
- Health fund status
- WorkCover status
- Contact details of person in case of emergency
- Name and contact details of other health service providers (i.e. Doctor)
- Details of inter-clinical referrals
- The date and time of each consultation including start and finish times
- Details of presenting conditions and symptoms
- Details of clinical findings, observations and examinations
- Details of treatment, remedies, advice and information provided during consultations
- Details of medicines, dosage rates etc
- Outcomes, results and improvements achieved
- Details of any previous or known adverse drug reactions
- Details of previous conditions, illnesses and information provided by the patient
- Details of any adverse health events
- Source of patient history (i.e. patient, interpreter or guardian)
- Details of any other medications being taken by the patient
- Deatils of any treatment/services provided by other health service providers
- Details of any treatments provided by hospitals or specialists
- Details of referrals to other practitioners
- Details of relevant family health history
- Details of any advice or recommendations provided
- Details of other relevant information provided by the patient
We have created a Guide to Clinical Record Keeping if you wish to download and use in your own clinics.