Clinical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting topic for health practitioners to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many health practitioners would benefit from learning more about good record keeping.

Clinical records and insurance claims

Clinical records can impact insurance claims in two ways:

1. Poor records which lack detail can lead to incorrect clinical decision making and poor clinical outcomes for the patient and therefore patient complaints.
2. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

Why keep detailed clinical records?

1. Continuity of patient care

It’s not uncommon to hear health practitioners claim they can remember the details of patient consultations. However at Guild, we regularly see examples where practitioners haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the patient. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated a patient in the past.

It’s also important to be sure you refer to the information within the patient’s record. Patients can suffer harm when information, such as allergy details, is overlooked or forgotten about and therefore the patient isn’t treated accordingly.

2. Regulatory requirement

All Australian Health Practitioner Regulation Agency (Ahpra) regulated practitioners need to be well aware of their many regulatory requirements; good record keeping is one of these. Each profession’s Code of Conduct contains information about a practitioner’s obligations and requirements regarding record keeping. Several Ahpra National Boards have also created a separate document on guidelines for clinical records which further explains what’s required.

It’s the responsibility of every registered health professional to make themselves aware of and comply with the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.

3. Defence of a complaint

If there’s any allegation of wrong doing made against a practitioner, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the practitioner will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a practitioner’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

4. Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for healthcare and can conduct audits to be sure health practitioners are billing appropriately.

It’s not uncommon for a health practitioner to receive a request from a funding provider to produce clinical records to justify their billing practices. This is another example of when a practitioner needs documented evidence of what they’ve done and why. If the reasons behind treatment, and therefore billing, isn’t clear, funding providers can demand repayment.

Record keeping requirements

What to record?

The key question many health practitioners ask when it comes to clinical record keeping is ‘how much detail do I need to record?’. Practitioners should refer to their Code of Conduct, as well as the guidelines on record keeping if one exists, to better understand the detail required in a clinical record.

Exactly what to include can vary according to the type of health profession as well as the specifics of the patient’s condition and treatment. However, generally records should include, but aren’t limited to:

• Patient identifying details and contact information as well as health history
• Name of the consulting practitioner and the date of the consultation
• Reason for the patient presentation
• All examinations and investigations conducted and their results, even if there is no abnormal finding
• Diagnosis and treatment plan
• Consent to treatment
• Treatment provided and the patient’s response
• Any items supplied, or instructions given, to the patient
• Referrals to other health professionals

In some cases, it’s worth noting what didn’t occur as well as what did. For example, if a patient has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined. If it’s simply left out of the record, it would appear that it wasn’t discussed as a treatment option.

When a practitioner is unsure if they have included enough detail, they should ask themself whether or not another practitioner could read the record and understand the full picture of what took place and why, without the treating practitioner filling in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Clinical records need to always be professional and objective. Negative comments about the patient can be included, however, this must be professional and only when this is relevant to the treatment being provided. This may occur in situations where the patient isn’t complying with instructions and this is detrimental to their health. However, it’s important to remember that clinical records can be accessed and read by a number of people, including the patient and your regulator, so always be mindful of the language used. The language used should match the professional language a health practitioner would use when speaking to the patient during a consultation.

Using Artificial Intelligence

As with many other parts of our lives, the use of artificial intelligence (AI) is creeping into record keeping practices more and more all the time. And while there are numerous potential benefits of using AI, there are also risks that health professionals need to understand and manage. The first step in this requires practitioners thoroughly research any AI tool they intend to use and be sure they understand how they work, particularly in relation to the storage and use of information input into them.

The task of creating appropriate clinical records can’t be left to AI; practitioners must be sure they review any AI‑generated information to be sure it’s detailed and accurate. And when doing this they must keep in mind that AI isn’t perfect; it will at times leave out important information and even make things up. It’s also important to be sure patients are aware of the use of AI. When patient data is being input into an AI tool or if consultations are being recorded, informed consent is a must.

For further information about the use of AI in healthcare, refer to guidance available from Ahpra that can be found at www.ahpra.gov.au/Resources/Artificial-Intelligence-in-healthcare.

Disposing of records

There’s no requirement to dispose of clinical records, and from a risk mitigation perspective, it’s advisable to keep them for as long as you can.

In New South Wales (NSW), Victoria and the Australian Capital Territory (ACT), it’s required that records for an adult patient are kept for 7 years from the last date of entry. For a patient who was under 18 years of age when the last record was made, those records need to be kept until that patient turns 25 years old. Other states and territories don’t have specific legislation regarding time frames for keeping health records. However, it’s recommended that practitioners in those states and territories adhere to the requirements for NSW, Victoria and ACT.

There’s varying legislation across the different states and territories regarding processes to adhere to when disposing of records. It’s recommended practitioners make themselves familiar with what’s required, if intending to dispose of records, and seek independent legal advice if needed or speak to your professional association.

Client record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for AEPs to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many AEPs would benefit from learning more about good record keeping.

Record keeping and insurance claims

Why is an insurer so concerned about record keeping? It’s because client records can greatly impact insurance claims in two ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

2. And surprisingly to some, poor records can contribute to poor or unexpected outcomes following sessions, such as an injury, leading to the client complaining and possibly seeking some form of compensation.

The wellbeing of clients is paramount, therefore reducing the potential risk of injury should be a priority to AEPs.  A potential risk when treating a client is a claim brought against a practitioner, which can lead to insurance claims. This can be a very challenging and confronting experience. Therefore, understanding how to improve the standard of client records really should be a core focus. 

Why keep detailed client records?

Continuity of service

It’s not uncommon to hear professionals say they can remember the details of their clients and any interactions with them. However, at Guild we regularly see examples where professionals haven’t remembered key aspects of their sessions or consultations, and this has led to a poor outcome for the client. It’s therefore imperative to record details about all sessions, with specific information about what exercises were performed and how the client responded to them. It’s also important to be sure you refer to this information within the client’s record when planning future sessions.

Professional expectation

All professionals need to be aware of the various expectations placed on them, which are there to assist people to carry out their work appropriately. And it’s a common expectation that professionals keep detailed records of client interaction. This is no different for AEPs.

In the ESSA Code of Professional Conduct and Ethical Practice, it states that ESSA members and accredited professionals must ‘keep accurate, clear, respectful, up-to-date records documenting services’. This Code can be found at www.essa.org.au/Public/Professional_Standards/ESSA_Code_of_Professional_Conduct___Ethical_Practice

Defence of a complaint

If there’s any allegation of wrongdoing made against a professional, their records are going to be incredibly important. Those records provide evidence of what took place and why when providing services to clients. Without this, the professional will be relying on their memory as a defence. Information recorded at the time of the session is going to hold greater weight as a reliable defence than a professional’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for services provided and can conduct audits to be sure professionals are billing appropriately. It’s not uncommon for a professional to receive a request from a funding provider to produce records to justify their billing practices.  If the reasons behind the service, and therefore the billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many professionals ask when it comes to client record keeping is ‘how much detail do I need to record?’.  Exactly what to include can vary according to the specifics of the client’s condition and services provided. However, generally records should include, but aren’t limited to:

• Client identifying details and contact information
• Pre exercise screening information
• Date of the session
• Relevant pre exercise discussion – for example, how the is client feeling and what their expectations are
• Details of the client’s informed consent, including the risks, benefits and potential outcomes that were discussed
• Details of all exercises performed including modifications made to the program and why
• Client’s response to exercises – did they struggle, feel pain or discomfort, are they ready to progress etc
• Any instructions given to the client for exercise outside of the session provided
• Referrals to health professionals or anyone else
  

When a professional is unsure if they‘ve included enough detail, they should ask them self whether or not another professional could read the record and understand the full picture of what took place, without the need to fill in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Client records need to always be professional and objective. Constructive critical comments about the client can be included, however this must be professional and only done when relevant to the service being provided. This may occur in situations where the client isn’t able to perform exercises correctly or isn’t complying with instructions when away from session, and this could lead to injuries or a lack of progression. However, it’s important to remember that client records can be accessed and read by several people, including the client, so always be mindful of the language used. The language should match the professional language a professional would use when speaking to the client during a session.

Medical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for veterinarians to spend time thinking and talking about. However, it’s incredibly important, and Guild’s claims management experience suggests veterinarians would benefit from learning more about good record keeping.

Records and insurance claims 

Records can impact insurance claims in two ways:

1. Poor records can contribute to a poor or unexpected outcome following treatment, leading to the client complaining and possibly seeking some form of compensation. For example, a dog’s weight was incorrectly recorded in the record due to a simple data entry error. This led to the dog being given a dose of medication which was too high; unfortunately the dog suffered renal damage and died as a result.

2. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence of what took place and why. Poor clinical outcomes and dealing with complaints can be very challenging and confronting. Therefore, understanding how to improve the standard of records really should be a focus.

Why keep detailed records?

1. Continuity of care

It’s not uncommon to hear veterinarians believe they can remember the details of their consultations. However, at Guild we see examples where veterinarians haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the animal. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated an animal in the past. It’s also important to be sure you refer to the information within the record. Animals can suffer harm when key information is overlooked or forgotten about and they’re therefore not treated accordingly.

2. Regulatory requirement

All State and Territory Veterinary Boards within Australia have some sort of guideline or policy about a veterinarian’s obligations and requirements regarding record keeping. It’s the responsibility of every veterinarian to make themselves aware of and comply with the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.

If there’s an allegation of wrong doing made against a veterinarian, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the veterinarian will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a veterinarian’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

What to record?

A question many veterinarians ask when it comes to record keeping is, ‘How much detail do I need to record?’ Veterinarians should refer to their relevant Veterinary Board’s information to better understand the detail required in a record. Exactly what to include can vary according to the specifics of the animal’s condition and treatment. However, generally records should include, but aren’t limited to:

• client identification
• treatment date
• animal(s) identification
• history
• examination details
• diagnosis
• treatment options offered and given, prescribed, or supplied
• informed consent
• response to treatment
• other records/reports such as imaging reports, laboratory reports or specialist/referral reports
• information provided to the client including post treatment instructions

In some cases, it’s worth noting what didn’t occur as well as what did. For example, if a client has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined. If it’s simply left out of the record, it would appear that it wasn’t discussed as an option.

When veterinarians are unsure if they have included enough detail, they should ask themselves whether or not another veterinarian could read the record and understand the full picture of what took place and why, without the treating veterinarian filling in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Records need to always be professional and objective. Criticisms of the client can be included, however this must be professional and only when relevant to the treatment being provided. This may occur in situations where the client isn’t complying with instructions and this is detrimental to the health of their animal. However, it’s important to remember that records can be accessed and read by a number of people, including the client and your regulator, so always be mindful of the language used. The language used should match the professional language a veterinarian would use when speaking to the client during a consultation.

Changes and corrections

If it’s noticed that errors have been made in a record, changes can be made to correct this. However, information should never be deleted. The original information must remain with a note explaining the correction and when the correction was made. Also, if additional information needs to be added to a completed consultation note, it should be done so it’s clear this is additional information and the date it was added.

Download PDF here

Client record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for health professionals to spend time thinking and talking about. However, it’s incredibly important and Guild’s experience suggests many health professionals would benefit from learning more about good record keeping. Client records and insurance claims Client records can impact insurance claims in 2 ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence. 

2. And surprising to some, poor records can contribute to a poor or unexpected outcome following a service being provided, leading to the client complaining and possibly seeking some form of compensation.

Why keep detailed client records?

It’s a widely accepted expectation that health professionals in Australia will keep detailed records of services provided, and this is no different for dietitians. To be sure records are kept to the standard required, it helps to understand why records are required and the purpose they serve.

1. Continuity of dietetic services

It’s not uncommon to hear health professionals claim they can remember the details of client consultations. However, at Guild we regularly see examples where professionals haven’t remembered key aspects of prior consultations and advice, and this has contributed to a poor outcome. It’s therefore imperative to have this information recorded to ensure certainty as to the services you’ve provided in the past and why.

It’s also important to be sure you refer to the information within the client’s record. Clients can suffer harm when information, such as allergy details, is overlooked or forgotten about and therefore the services and advice provided aren’t appropriate.

2. Defence of a complaint

If there’s any allegation of wrongdoing made against a dietitian, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the dietitian will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a dietitian’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence.’

3. Funding audits

Funding providers, such as private health insurers, regularly review the rebates they pay for services and can conduct audits to be sure health professionals are billing appropriately. Health professionals may receive a request from a funding provider to produce client records to justify their billing practices. If the reasons behind the service, and therefore billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many health professionals ask when it comes to client record keeping is ‘how much detail do I need to record?’ Exactly what to include will vary according to the specifics of the client and services provided. However, generally records should include, but aren’t limited to:

> Client identifying details and contact information as well as health history.

> Name of the consulting dietitian and the date of the consultation.

> Reasons for accessing services.

> Informed consent provided.

> Services and advice provided and the client response to this.

> Any items supplied, or instructions given, to the client.

> Referrals to other health professionals.

When a dietitian is unsure if they’ve included enough detail, they should ask themself whether another dietitian could read the record and understand the full picture of what took place and why. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Client records need to always be professional and objective. Constructive critical comments about a client can be included, however this must be professional and only when this is relevant to the services being provided.

This may occur in situations where the client isn’t complying with instructions or advice, and this is detrimental to their health outcomes. However, it’s important to remember that clinical records can be accessed and read by several people, including the client, so always be mindful of the language used. The language should match the professional language a dietitian would use when speaking to the client during a consultation.

Download PDF article here.

Client record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for fitness professionals to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many fitness professionals would benefit from learning more about good record keeping.

Record keeping and insurance claims

Why is an insurer so concerned about record keeping? It’s because client records can greatly impact insurance claims in two ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

2. And surprisingly to some, poor records can contribute to poor or unexpected outcomes following training sessions, such as an injury, leading to the client complaining and possibly seeking some form of compensation.

All fitness professionals would want to avoid client injuries as the wellbeing of their clients is paramount.  They would also want to avoid complaints, which can lead to insurance claims, as these can be very challenging and confronting experiences. Therefore, understanding how to improve the standard of client records really should be a core focus.

Why keep detailed client records?

Continuity of service

It’s not uncommon to hear professionals say they can remember the details of each of their clients and any interactions with them. However, at Guild we regularly see examples where professionals haven’t remembered key aspects of their sessions or consultations, and this has led to a poor outcome for the client.  It’s therefore imperative to record details about all training sessions, with specific information about what exercises were performed and how the client responded to them.  It’s also important to refer to this information within the client’s record when planning future sessions. 

Professional expectation

All professionals need to be aware of the various expectations placed on them, which are there to assist them to carry out their work appropriately.  And it’s a common expectation that professionals keep detailed records of client interaction; this is no different for fitness professionals.

In the AUSactive Code of Ethical Conduct, it’s stated that AUSactive professionals are required to ‘Maintain complete records of services provided to clients, including records of pre-exercise screening, client progress, and referrals’. 

Defence of a complaint

If there’s any allegation of wrongdoing made against a fitness professional, their records are going to be incredibly important. Those records provide evidence of what took place and why during sessions with clients. Without this, the professional will be relying on their memory as a defence. Information recorded at the time of the session is going to hold greater weight as a reliable defence than a professional’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for services provided and can conduct audits to be sure professionals are billing appropriately. It’s not uncommon for a professional to receive a request from a funding provider to produce records to justify their billing practices.  If the reasons behind the service, and therefore the billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many professionals ask when it comes to record keeping is ‘how much detail do I need to record?’. Exactly what to include will vary according to the specifics of each fitness session as well as the individual client.  However, generally records should include, but aren’t limited to:

• Client identifying details and contact information
• Pre exercise screening information
• Date of the session
• Relevant pre exercise discussion – for example, how the client is feeling and what their expectations are 
• Details of all exercises including
  • Warm up and cool down exercises
  • Core program exercises
  • Number of reps
  • Number of sets
  • Weights or resistance level
  • Modifications made to the program
• Client’s response to exercises – did they struggle, feel pain or discomfort, are they ready to advance in the program etc
• Any instructions given to the client for exercise outside of the session times
• Referrals to health professionals or anyone else
  

When a professional is unsure if they’ve included enough detail, they should ask them self whether or not another professional could read the record and understand the full picture of what took place, without the need to fill in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Client records need to always be professional and objective. Constructive critical comments about the client can be included, however this must be professional and only done when relevant to the exercise instruction being provided. This may occur in situations where the client isn’t able to follow instructions or perform exercises correctly and this could lead to injuries or a lack of progression.  However, it’s important to remember that client records can be accessed and read by several people, including the client, so always be mindful of the language used. The language should match the professional language a fitness professional would use when speaking to the client during an exercise session.

Download pdf article here.

Patient record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for natural therapists to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many practitioners would benefit from learning more about good record keeping.

Patient records and insurance claims

Patient records can impact insurance claims in two ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

2. And surprisingly to some, poor records can contribute to a poor or unexpected outcome following treatment, leading to the patient complaining and possibly seeking some form of compensation.

All natural therapists would want to avoid poor patient outcomes as the wellbeing of their patients is paramount. However, they would also want to avoid complaints, which can lead to insurance claims, as these can be very challenging and confronting experiences. Therefore, understanding how to improve the standard of patient records really should be a focus.

Why keep detailed patient records?

1. Continuity of patient care

It’s not uncommon to hear practitioners believe they can remember the details of patient consultations. However, at Guild we regularly see examples where practitioners haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the patient. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated a patient in the past.

It’s also important to be sure you refer to the information within the patient’s record. Patients can suffer harm when information, such as allergy details, is overlooked or forgotten about and therefore the patient isn’t treated accordingly.

2. Regulatory requirement

All professionals need to be aware of the various expectations placed on them, which are there to assist people to carry out their work appropriately. And it’s a common expectation that practitioners keep detailed records of patient interaction. This is no different for natural therapists.

In the Australian Natural Therapists Association (ANTA) Code of Professional Ethics, it states that practitioners are to ‘Maintain accurate, complete and up-to-date clinical records’.

The Code of Conduct for the Australian Health Practitioner Regulation Agency (Ahpra) states that ‘Maintaining clear and accurate health records is essential for the continuing good care of patients’.

It’s the responsibility of every practitioner to make themselves aware of and comply with the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.

3. Defence of a complaint

If there’s any allegation of wrong doing made against a practitioner, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the practitioner will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a practitioner’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

4. Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for treatment and can conduct audits to be sure practitioners are billing appropriately. It’s not uncommon for a practitioner to receive a request from a funding provider to produce patient records to justify their billing practices.  If the reasons behind treatment, and therefore billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many practitioners ask when it comes to patient record keeping is ‘how much detail do I need to record?’. Natural therapists should refer to ANTA’s Guide to Clinical Record Keeping to better understand the detail required in a patient record.

Exactly what to include can vary according to the specifics of the patient’s condition and therapy provided.  However, generally records should include, but aren’t limited to:

• Patient identifying details and contact information as well as health history
• Name of the consulting practitioner and the date of the consultation
• Presenting conditions and symptoms
• All examinations and investigations conducted and their results
• Informed consent to treatment
• Treatment provided and the patient’s response
• Any items supplied, or instructions given, to the patient
• Referrals to other health professionals.

When a practitioner is unsure if they’ve included enough detail, they should ask them self whether or not another practitioner could read the record and understand the full picture of what took place and why, without the treating practitioner filling in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Patient records need to always be professional and objective. Constructive critical comments about the patient can be included, however this must be professional and only when this is relevant to the treatment being provided. This may occur in situations where the patient isn’t complying with instructions and this is detrimental to their health. However, it’s important to remember that clinical records can be accessed and read by a number of people, including the patient, so always be mindful of the language used. The language used should match the professional language a practitioner would use when speaking to the patient during a consultation.

Download PDF article here