Part one: Exploring best practice note-taking and record-keeping in health care

by | Sep 13, 2019 | Health Blog

There is a general expectation that health care professionals meet their note-taking and record-keeping obligations.

In part one of exploring best practice in note-taking and record-keeping we look at:

  • Why records should be kept
  • Current laws and codes relevant to note-taking
  • Using and disclosing records
  • How notes should be taken
  • Whether records can be altered
  • Length of time records should be kept

Why keep records?

Adequate records serve as a reminder of important information, provide a summary of what has been told or observed, set out advice and recommendations that have been made and allow for continuity of care. Health records are also important to support billing practices.

What are the current laws and codes relevant to note-taking?

All National Boards for health care professionals have implemented Codes of Conduct which include the requirement to maintain clear and accurate health records. Some of the current laws and codes relevant to note-taking include the:

  • National Safety and Quality Health Service Standards (NSQHSS) (2nd edition);
  • Good medical practice: a code of conduct for doctors in Australia;
  • APS Code of Ethics;
  • Registered Nurse Standards for Practice; and
  • Privacy Act 1988 (Cth).

When can records be used or disclosed?

According to Australian Privacy Principle 6 (APP6) an APP entity can only use or disclose personal information for a purpose for which it was collected. An APP entity can use or disclose information in situations where:

  • The information is used for the particular purpose for which it was collected (primary purpose).
  • Consent is provided for another use (secondary purpose).
  • It is reasonably expected that the information will be used for a secondary purpose that is related to the primary purpose.
  • There are laws requiring or authorising use or disclosure.
  • There is a need to prevent a serious threat to life, health or public safety.

How should notes be taken?

When writing notes, always assume that they will be viewed by the client or patient. The tone of the note should be respectful and non-discriminatory, mindful of the client’s perspective and likely reaction to the notes being read, and succinct, legible and comprehensible.

Listed below are best practice tips for note-taking:

  • Provide sufficient level of detail to easily determine what service was provided.
  • Include details of assessments and treatment methodology.
  • Avoid value judgments and prejudicial comments.
  • Outline services provided and any plans for future intervention.
  • Be objective and record the facts, reports, statements and behavioural observations.
  • Identify “verbatim comments” with quotation marks.
  • Include clinical judgments that are important for care delivery.
  • Document any consultation or supervision provided by others.
  • Ensure all notes are signed and dated.
  • Notes should be contemporaneous or completed within a reasonable time following service provision.

Can records be altered?

Yes, corrections to records can be made. Alterations can be made by ruling out the mistaken entry (without deleting it), initialling the correction and inserting the date when the correction is made and adding in the correct or additional information clearly showing the entry date and author.

How long should records be kept?

There is currently no legislation in Western Australia mandating the retention or destruction of private practice health records. However, it is generally recommended that records are retained for:

  • Seven years from the date of the last contact with the client; or
  • For children – until they reach the age for 25 years or seven years after their last attendance (whichever is later).

Under the Western Australian State Records Act 2000, the health records of discharged patients and outpatients of public hospitals are generally kept for 15 years after the date of the last attendance.

The medical records of any patient treated in a State health facility for a psychiatric illness are to be kept for a minimum of seven years following death, and the records pertaining to Aboriginal patients must be retained indefinitely for patients with a date of birth prior to and including 1970. Additionally, all remote clinic patient records from the Pilbara and Kimberley regions must be kept indefinitely.

Keep an eye out for part two of exploring best practice in note-taking and record-keeping, where we explore the pros and cons of electronic and paper records, ‘the cloud’ and managing associated risks, and notifiable data breaches.

If you would like further information on this topic, or if you would like to review your policies, procedures or training requirements, please contact Gemma McGrath

Gemma McGrath

Gemma McGrath