What are record keeping professional obligations?

The Code of conduct shared by 12 national boards, including the Physiotherapy Board of Australia, includes a number of obligations for health practitioners in relation to maintaining clear and accurate health records to ensure that good care is provided to patients.

The obligations relate to the form of health records as well as what information is required to be included.

Clinical scenario

Stella attends for an initial consultation with a physiotherapist, Jack, presenting with severe back pain.

Jack asks about Stella’s medical history and she advises Jack that she has arthritis and has previously had a steroid injection, which was ineffective.

Jack conducts an assessment and diagnoses Stella with degenerative disc disease.

He explains to Stella that he recommends soft tissue massage as well as some core stabilisation exercises and seeks her verbal consent to proceed with the soft tissue massage, which Stella provides.

During the treatment, Stella advises Jack that she also has pain in her right knee and would like to seek treatment from him for this.

Jack advises Stella that he would be happy to provide treatment for her knee and he would do a thorough assessment and treatment during their next consultation.

At the end of this consultation, Jack also provides Stella with core stabilisation exercises to be completed at home and they schedule a follow-up consultation for a week’s time.

Prior to this follow-up consultation, Jack feels unwell and has a few days off work.

He reschedules his patients, including Stella, to another physiotherapist at the clinic, Laura.

He then quickly completes notes for all the patients Laura will be seeing.

In Stella’s notes, he writes, ‘Soft tissue massage for DDD, at-home exercises given.’

During the follow-up consultation, Laura says to Stella, ‘I can see from Jack’s notes that you are here for degenerative disc disease. You could try a steroid injection for that’, to which Stella responds that she has already tried a steroid injection and she had advised Jack of this during the first consultation.

Laura then explains to Stella that she will continue with the soft tissue massage provided by Jack and she will also review the exercises provided.

Stella advises Laura that she had discussed with Jack having an assessment and treatment of her right knee during this session.

Laura responds that she would be happy to do this, completes an assessment of Stella’s right knee and provides soft tissue massage.

At the end of the session, Stella is annoyed that Jack had not properly advised Laura about her medical history, nor that she wanted treatment on her right knee, and makes a complaint to the clinic.

Jack has breached his professional obligations under section 8.3 of the Code of conduct by:

• failing to keep accurate records that report relevant details of Stella’s history, the verbal consent obtained, any information or treatment (including exercises) provided to Stella and the future treatment plan
• failing to ensure that his health records were sufficient to facilitate Stella’s continuity of care upon consulting with Laura
• failing to ensure that his health records contained sufficient detail and were accurate enough to enable them to be understood by Laura
• failing to make his records at the time of his consultation with Stella or as soon as possible afterwards.

Learnings and safeguards

Safeguards to improve record keeping include:

• ensuring that notes contain all the information that would be needed for a practitioner taking over a patient’s care
• always assuming that someone else (including the patient) will see the notes
• obtaining and documenting a clear, complete and accurate patient history, including clinical findings, investigations, information provided and medication or other management
• writing notes contemporaneously. If any information is retrospectively added to notes, ensuring that this is clearly recorded as an amendment by noting the name of the person making the amendment and the date
• always recording the information necessary to demonstrate that the patient provided informed consent.

Safeguards that may assist clinics to ensure that physiotherapists are taking accurate and sufficiently detailed notes include regular training for staff on note-taking and professional obligations relating to health records.

Clinics can also consider developing and implementing note-taking policies and procedures, including templates to assist physiotherapists.

This article is part of the risk management series facilitated by APA’s insurance partner BMS and written by health firm Barry.Nilsson. Lawyers.

Disclaimer: Barry.Nilsson. Lawyers communications are intended to provide commentary and general information. They should not be relied upon as legal advice. Formal legal advice should be sought in particular transactions or on matters of interest arising from this communication. BMS Risk Solutions Pty Ltd (BMS) AFSL 461594 ABN 45 161 187 980 is the official and exclusive insurance broker for the APA member insurance program. BMS is part of the wider BMS group, which is dedicated to providing coverage and value-added services to associations and their members. BMS group includes Lloyd’s broker BMS Group Ltd. The BMS group provides cover to more than 700,000 healthcare and regulated professionals through more than 100 associations across Australia, Canada, Europe and New Zealand.