122263 - Noteworthy: The How, What, Where and Why of Medical Documentation – Online Activity
- : Online
Medical records are integral to good quality patient care. They enable continuity of care, reduce errors, and improve outcomes. This interactive online activity helps doctors and practice managers create good quality medical records and deal with medical documentation issues, such as release to third parties, secure storage of personal information, retention of records, and access to records when leaving a group practice. The activity covers how to avoid pitfalls of electronic record keeping and uses case scenarios and quiz questions. Take home, downloadable information is supplied. The activity focusses on areas identified as being problematic for doctors in recent court and medical board findings, the medical literature, feedback at education activities, and a medical indemnity insurer’s advice requests and claims and complaints experienceRelevance to General Practice
Numerous recent court and Medical Board of Australia findings have been made relating to inappropriate medical record keeping (including cases involving General Practitioners). Not adequately documenting informed consent conversations is a notable theme in court findings.
The sensitive nature of information in medical records means that a privacy error with clinical documentation is a serious breach of the Privacy Act.
A general practice’s record storage may be disrupted for many reasons (e.g. renovation, relocation, retirement, new ownership) and the requirements for appropriately managing medical records are complex. In 2014 the Australian Privacy Commissioner found that a medical centre breached the Privacy Act by not sensibly securing personal information.