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Managing Patient Records
There are many reasons to keep good, legible and backed-up patient records. Patients rightly expect that notes kept about them contain up-to-date, accurate details of their medical history. Whether a paper-based or electronic system is used, all entries should be dated correctly.
Retaining records for evidenceKeep patient records for as long as physically possible. If you don't have the space, scan the records and save them on your hard drive - and also back them up to CD.
If you haven't kept any records, we can still assist you - it just makes the process more difficult for the doctor and staff involved.
Changing patient recordsYou, or anyone at your direction, must not alter a record in a way that would obliterate, obscure or make illegible any information in it. (Medical Practice Act 1992) Changes should not be made to notes after the date of the consultation. It is however, acceptable to make additions to the notes at a later date, as long as you record the date upon which you add them.
LegislationEach state in Australia has its own Act which sets out the record keeping regulations for medical practices.
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