We regularly assist health practitioners who are experiencing issues not relating to any concerns about competency, but because they are unable to confirm or justify aspects of their management due to inadequate record keeping.
The following tips will assist you when making records or reviewing your usual practices:
- In Australia, patients generally have a right to access their ‘health information’, which includes their medical records. Create your records with the knowledge that they could be viewed by the patient or other interested parties (such as Ahpra or a civil court). Avoid making value judgments or prejudicial statements in your records.
- Be objective when creating records. Record the facts, reports, statements and any behavioural observations. Record information chronologically to the greatest extent possible and in consecutive order. Do not use jargon, meaningless phrases or include personal opinions about non-clinical matters.
- Try to record the relevant information as clearly as possible. If multiple parties are involved in an interaction, identify them by name rather than by pronouns. Only use abbreviations that are commonly understood. For example, BP and VA will be recognized by a majority of health professionals, but FLK may not be understood or acceptable!
- Don’t make incomplete records because you intend to rely on your memory to recall previous interactions. Many practitioners, particularly for long term patients, create brief records because they are well across the patient’s issues and management. Your records must be complete and allow another health practitioner to immediately pick up where you left off in the event you are unavailable.
- If you need to make an alteration to a record – do not delete the original entry. Addendums to records should be made underneath or beside the original entry, noting the date the addendum was inserted along with your initials or name. For paper records, you can rule through errors to show why the alteration was made, but the error should not be deleted altogether and should remain legible.
For further insight on potential disciplinary outcomes related to record keeping issues, see our recent Case summary.
