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.

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Are you prepared for a power outage?

Power outages are unfortunately becoming a somewhat common occurrence in parts of Australia. The threat of heatwaves, and therefore higher than usual demands on power, means that power outages are a real threat to many businesses over summer.

Insurance protection during a power outage

It’s important that all businesses understand their insurance cover in case of events which impact the running of the business, such as a power outage. Guild Insurance will provide cover when the power outage is unplanned, and this is defined as when there is less than 48 hours’ notice that the outage will occur. Cover will be provided for the cost of hiring a generator. And the really beneficial part about this cover is that there’s no waiting period with Guild Insurance. So if the power is out for only 2 hours, the policy will still respond and provide cover for that short period.

Planning for an outage

Sometimes there is no notice that a power outage is to occur. And even when notice is given, there may not be enough time to allow a business to adequately prepare for the outage. Therefore it’s vital that all businesses have a plan in place, sometimes referred to as a business continuity plan, for what they’ll do if a power outage was to affect their business.

Some factors to consider when making this plan include:

• Is there a business nearby which provides generators for backup power?
• Can the business continue running from another site or location?
• Is there another location where items, such as refrigerated stock, can be stored so they don’t perish or become damaged?
• Where will emergency contact details (e.g. power company, insurer, clients) be stored away from the business in case the business can’t be accessed?
• What are the implications for both the business and clients if the business doesn’t operate for a period of time?

Remember, planning during an outage is too late. Don’t think this won’t happen to you, have a plan just in case.

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When considering an insurance policy, it’s easy for many of us to think “it’ll never happen to me”.  However, the vast experience of Guild Insurance tells us ‘it’, being events that require insurance claims, unfortunately can happen to people like you. 

Guild Insurance is dedicated to providing risk management information to those insured with us to help reduce the likelihood of events occurring which will have a detrimental impact on their business and lead to an insurance claim.  However, we also know that not everything can be prevented.  Which is why business owners also need to consider what they can do to reduce the severity or impact on their business should an event occur.  And this is where asset registers become so important.

What is an asset register?

An asset register is simply a list of assets held by a business.  These can be created and stored in various ways, such as paper format or electronically, yet should always be stored safely and be easily accessible.

Why are they needed?

All businesses should hold an asset register as they serve a number of important purposes.

It’s estimated that well over half of Australian businesses are underinsured.  A detailed asset register will help a business understand the value of what they own and therefore the level of insurance required to be adequately protected.

An asset register also assists businesses when there is a need to lodge an insurance claim due to property loss or damage.  When there is an up to date asset register, this necessary information can be provided quickly to an insurance company which is likely to speed up the settlement process.  Making an insurance claim for property damage or loss can be quite a stressful process for any business.  An asset register can reduce some of this stress by making the process more straightforward.

When a business has multiple sites, keeping track of all assets is quite a challenge.  An asset register provides the business with a way to manage all assets, even when the assets aren’t physically in sight of those responsible.

What information should be included?

For an asset register to be of any benefit to a business, it’s important that the information is up to date and correct.  Businesses should have a process for how and when the register will be updated and by who.  This process should require adding a new asset as soon as it is purchased.  However, it would also be beneficial doing regular checks of the asset register to be sure nothing has been accidentally left off.

The asset register should include a list of all items which could be lost or damaged if there was an incident at the premises.  Don’t just focus on the costly items; damage to a lot of items which are of lesser value can still add up and you will want a record of these items.  The types of assets to be recorded may include:

• Furniture, both indoor and outdoor
• Computer and other office equipment
• Electrical items such as fridges and air conditioners

The information to record about each of these items may include:

• Description of the item
• Brand, make or model
• Serial number
• Purchase value
• Purchase date
• Location of the item
• Warranty information
• Invoices

Creating an asset register

As previously mentioned, asset registers are really just a list of items so the creation of them doesn’t need to be overly complex.  There are a number of template examples which can be found through internet searches. 

However, the challenging aspect of creating an asset register is being sure the information you have on there is detailed and correct.  It’s therefore recommended that businesses use their accountant to assist with this task.

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