Patient health records

Patient case records are legal documents. An adequate record of every patient consultation is an essential part of competent Chinese medicine practice for the following reasons:

• Good patient case records facilitate high-quality and comprehensive care by making detailed and relevant information (current and historical) readily available to any treating practitioners.
• Patient case records can provide a repository of valuable information for teaching, education and research.
• Patient case records should be the basis for quality management and improvement activities undertaken regularly by Chinese medicine practitioners.
• Patient case records form the basis for retrieval of treatment details to assist in disputes or in giving evidence and may, in themselves, be used as evidence in courts and tribunals.

The Board's Guidelines: patient health records refers to two types of records; i) accounting records and ii) clinical records.

Accounting records

Taxation law requires small business accounting records to be held for at least 5 years after they were prepared, and for longer if they are to be used in a later tax return.

See the Australian Taxation Office website for more information on record keeping for small business.

Clinical records

All states have requirements for health record retention in the public sector, but only Victoria, NSW and ACT have laws which apply to private sector health records. In these states private sector health records must be kept for seven years after the last treatment was provided for an adult patient. Where the patient was aged less than 18 years, records must be kept until the patient turns 25 years old.

In states without specific record retention policies registrants are reminded that records are created and maintained to serve the best interests of patients and to contribute to the safety and continuity of their Chinese medicine care. Patient records are also necessary to respond to patient complaints. For these reasons records should not only be retrained until they are no longer required to manage the patients care, but also until after the statute of limitations on personal injuries has expired in that state.

It is the registrant’s responsibility to be familiar with and comply with their relevant state laws regarding patient health record retention.

Generally, the health service provider who creates a medical record owns that record. In a group practice however, the owner of the records will depend on the contractual relationship between the practice owner and the practitioner. To avoid disputes, registrants should clarify the matter of ownership of patient records before commencing practice in a group practice.

Commonwealth privacy legislation still gives patients’ rights regarding access to a patient’s records irrespective of who owns the records.

Read more about My Health Record - the national digital health record system.