Creating and keeping medical records

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.

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.

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.