186164 - Noteworthy: The How, What, Where and Why of Medical Documentation - Online Activity
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 experience
Relevance 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.
- Outline what constitutes appropriately-detailed clinical notes.
- Employ the mnemonic “SOAP” to create logical and appropriate clinical notes.
- Explain the medico-legal requirements on when and how to release information in medical records to others.
- Recognise common problems with medical records that can adversely affect patient care and medico-legal outcomes.
- Facilitate secure storage and retention of, and access to, medical documentation.
- Domains of General Practice
D1. Communication skills and the patient-doctor relationship
D2. Applied professional knowledge and skills
D3. Population health and the context of general practice
D4. Professional and ethical role
Adherence to relevant codes and standards of ethical and professional behaviour
D5. Organisational and legal dimensions
Medico-legal requirements are integrated into accurate documentation
- Adult health
- Care of older people
- Children and young people health