Health records

Clear, accurate records are essential to continuing good care, and some Boards have specific records guidelines. Good practice means the practitioner: (a) keeps accurate, current, factual, objective, legible records of relevant clinical history, findings, investigations, information given, medication and other management, understandable to other practitioners; (b) keeps records secure from unauthorised access, safeguarding the privacy and integrity of electronic records in particular; (c) keeps records respectful and free of demeaning or derogatory remarks; (d) makes records sufficient for continuity of care; (e) writes records when events happen or as soon as practicable afterwards; (f) recognises and facilitates patients' right to access their records; and (g) promptly facilitates transfer or management, disposal included, of health information under privacy and health records law at a patient's request or on closure or relocation of a practice.

• Record-keeping audit against the Board's records guidance (history, findings, investigations, information given, medication, plan)
• Access controls and audit trail of the clinical records system
• Records retention and disposal schedule under the state or territory health records law
• Log of patient access and transfer requests

• Records written days after the consultation
• Shared logins to the clinical system
• Illegible or incomplete handwritten notes
• No retention or disposal rule