Client Record Keeping for Dietitians

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.

Similar Articles