Patient records are fundamental to all patient healthcare activities; they form part of a practitioner’s ethical and regulatory responsibility in providing good patient care. Patient records (legible handwritten or electronic) need to be created at the time of a patient’s presentation (or as soon as possible afterwards), and must be accurate, clear and concise, documenting the patient’s health care from their initial presentation, through their examination, diagnosis and ongoing care in chronological order, demonstrating the continuity of care and the patient’s response to treatment. The documentation should be sufficiently comprehensive to allow another colleague to continue the patient’s care if the treating practitioner were unavailable.
Things have changed over the years, and as accountable and progressive practitioners, we have to modify our practices too – we need to refresh. In the past, a small hand written card was acceptable; but today, a patient’s record may also include copies of emails, scanned records, consent forms and records of text messages. If there has been other communication, such as verbal correspondence between health professionals, legal reports, referral letters, investigation reports, laboratory results, X-ray reports and the like, copies of these should also be filed.
The Chinese Medicine Council of NSW is responsible for handling notifications or complaints about Chinese Medicine practitioners in NSW. Unfortunately, when the Council is reviewing patient records following a notification or complaint, the patient record often reveals inadequacies. The Chinese Medicine Board of Australia has published Clinical Record Guidelines which clearly set out the requirements. If you haven’t read it – it is a must – refresh – don’t rely on old habits! Use the Board's guidelines to draft your patient record template (http://www.chinesemedicineboard.gov.au/Codes-Guidelines.aspx).
Patient records are legal documents. In the event of a complaint, they can be the practitioner’s most important evidence of good clinical care. Make sure you are adequately protected and that you offer your patients optimum care through good record keeping.
(Click here to read this article in Chinese)