Concise Advice

Creating and keeping medical records

Last reviewed/updated: 01 Jun 2022

Relevant normal findings can be as important to record as abnormal ones when they’re part of your clinical reasoning process, e.g. when a normal finding can help exclude a serious diagnosis.

Both paper and electronic records should include all material relevant to a person’s health care such as:

  • clinical notes
  • investigations
  • information given to patients
  • medication and other management
  • letters to and from other healthcare providers
  • multimedia, e.g. photographs and video
  • details of phone calls with the patient or other healthcare professionals.
Maintaining clear and accurate medical records is essential for the continuing good care of patients.

The code of conduct for doctors in Australia, section 10.5, says that records should be:

  • accurate, relevant and understandable
  • securely held
  • respectful
  • sufficient to facilitate continuity of patient care
  • contemporaneous.
It’s your responsibility to protect patient confidentiality by making sure records are not lost, stolen, damaged or altered.

You have a legal duty (Australian Privacy Principle 11) to have safeguards in place to protect your patients’ health information. Security measures include:

  • computer firewalls, virus protection, password protection and backups
  • lockable physical security for paper records
  • secure transfer of information
  • appropriate staff access levels
  • ongoing monitoring of data security.

MDA National recommends that medical records should be kept:

  • for seven years from the last entry date for an adult patient
  • until the person is 25 years of age where the patient is a child.

If there has been a patient complaint, adverse outcome, or legal proceedings, the medical records should be kept indefinitely – or seek advice from your medical indemnity insurer before disposing of them.

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The information on this page is a guide only. Members are encouraged to contact us directly for specific advice. If you are not an MDA National Member, contact your medical indemnity insurer for advice specific to your situation.