Medical Record-keeping Matters
Medical record-keeping really matters.
We recently assisted a health practitioner to respond to a patient’s complaint to AHPRA. The complaint was fairly serious, alleging incorrect advice about, medications, adverse long-term consequences for the patient’s health and consequent impacts to their family situation.
The patient also alleged inconsiderate behaviour and inattention by the practitioner including by taking a long phone call that interrupted the consultation.
The practitioner’s notes had enough content to show that:
- the allegation of incorrect advice was unfounded;
- the practitioner had changed her schedule at some inconvenience to herself to accommodate the patient who had missed their first appointment; and
- because of the change of schedule, the practitioner could not avoid having to (confidentially) take an urgent phone call about another clinical matter.
The complaint went no further.
What We Usually See
Unfortunately, our usual experience is that the practitioner’s notes are less helpful when it comes to responding to a regulatory authority’s enquiry.
For example in Professional Services Review (PSR) matters a recurring concern has been that the practitioner’s records for a particular service may hardly differ between patients, with little or no clinical information particular to the patient across a sample of up to 30 patient records.
In these cases, our solemn duty is to discuss with the practitioner that natural laws come into play that have a peculiar affinity with Newton’s laws of motion. We call them the Laws of Medical Record-Keeping and have included them below. We hope you find them helpful.
WorkLegal’s Laws of Medical Record-Keeping
Newton’s Law 1*: Unless a body (such as a rubber ball, car, or planet) is acted upon by some force, a body in motion tends to remain in motion and a body at rest tends to remain at rest.
Corresponding Medical Record Keeping Law 1**: Unless a medical record is acted upon by the medical practitioner to, inter alia, contain clinical information sufficient to explain the service, it will tend to remain devoid of utility to anyone, especially the practitioner’s concerned lawyer.
Newton’s Law 2*: When an external force acts on a body, it produces an acceleration (change in velocity) of the body in the direction of the force.
Corresponding Medical Record Keeping Law 2**: When a medical practitioner who has not been attentive in their record-keeping receives a notice of PRP or PSR review, it will produce a sharp acceleration in the practitioner’s blood pressure and a deep sense of sadness in the practitioner’s concerned lawyer.
Newton’s Law 3*: When two bodies interact, they apply forces to one another that are equal in magnitude and opposite in direction. This is commonly referred to as the law of action and reaction (commonly stated as “every action has an equal and opposite reaction”).
Corresponding Medical Record Keeping Law 3**: In this respect (only) do Newton’s Laws of Motion differ from the laws of medical record-keeping. In the latter case, when the aforesaid previously inattentive practitioner (now with high blood pressure) and a relevant regulatory authority interact, typically the forces apply in one direction only…
*Source: Encyclopaedia Brittanica
**Source: The combined experience of a concerned legal fraternity including WorkLegal Lawyers.