Good practice involves good record keeping

 

Accurate and clear health records are essential for continuing high- value care of patients and clients. The Physiotherapy Board of Australia (the Board) is reminding physiotherapists about their regulatory obligations to keep good clinical records because concerns can be raised if record keeping falls below par.

As registered health practitioners, physiotherapists are expected to create and maintain clear, accurate and up-to-date clinical records for every patient. These records should contain enough detail to enable another practitioner to take over the care of the patient if necessary.

This should be simple; however, the Australian Health Practitioner Regulation Agency (AHPRA) and national boards receive a range of complaints and concerns every year about registered health practitioners, many of which include poor record keeping.

Like other registered health practitioners, physiotherapists have obligations under the Health Practitioner Regulation National Law to maintain good clinical records whether in electronic or paper form. Poor record keeping is often a component of complaints raised with the Board about a physiotherapist.

The professional obligations for physiotherapists are set out in the Physiotherapy Board of Australia’s Code of Conduct (the Code) in section 8.4, which states: maintaining clear and accurate health records is essential for the continuing good care of patients or clients. Practitioners should be aware that some National Boards have specific guidelines in relation to records. Good practice involves:

keeping accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management in a form that can be understood by other health practitioners

  • ensuring that records are held securely and are not subject to unauthorised access, regardless of whether they are held electronically and/or in hard copy
  • ensuring that records show respect for patients or clients and do not include demeaning or derogatory remarks
  • ensuring that records are sufficient to facilitate continuity of care
  • making records at the time of events or as soon as possible afterwards
  • recognising the right of patients or clients to access information contained in their health records and facilitating that access, and
  • promptly facilitating the transfer of health information when requested by patients or clients.

The Board does not stipulate how physiotherapists keep records; however, they must adhere to the Code which provides a framework for professional and ethical practice. Physiotherapists are measured against the Board’s registration standards, codes and guidelines if a concern is raised about them with the regulator. The Board will be seeking the views of practitioners as part of a scheduled review of its code of conduct.

Patient case records are legal documents. Physiotherapists must also ensure that access, transfer and management of patient clinical records is in accordance with the legislation governing health records in the state or territory in which they practise.

Board chair, Kim Gibson, is asking practitioners to keep in mind that their professional obligations extend to ensuring that records are accurate and held securely. ‘Physiotherapists have ethical and legal obligations to protect the clinical records of people requiring and receiving care. Patients or clients have a right to expect that practitioners hold information about them in confidence, unless information is required to be released by law or public interest considerations,’ Kim says.

‘Physiotherapists need to make sure the records are accurate and not subject to unauthorised access, regardless of whether they are held electronically or in hard copy. How records are managed is constantly changing. My advice to practitioners is to make sure you understand new methods of digital storage and the implications from the Australian Digital Health Agency’s My Health Record roll out.’ she added.

Visit the website to read your registration standards, codes, guidelines and FAQ. For registration enquiries, call 1300 419 495 (from within Australia) or 03 9275 9009 (for overseas callers).

 

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