Good Health Records Are Essential

If a medical or health practitioner receives a patient complaint or claim, one of the requests the medical practitioner may be asked by their medical indemnity insurer is for a copy of the patient’s health records. A request for patient records can often be prompted also by the patient or their solicitor.

A medical practitioner must keep good records

Having adequate records that pertain to the clinical management of a patient’s care are essential for a few reasons:

  • The ability to defend against claims and complaints
  • To refute complaints of inadequate clinical management or unprofessional conduct.
  • To justify the services carried out.
  • As a tool for benchmarking against best practice and seeking ways to improve any processes or procedures. 

There can be no denying that:

  • Good Records = Good Defence
  • Bad Records = Bad Defence
  • No Records = No Defence

Medical indemnity insurance quote

Tego Insurance can guide you to make the right decisions

When it comes to medical indemnity insurance and medical malpractice insurance one of the key areas of cover is for dealing with and responding to complaints and claims. Medical practitioners should always seek support and advice from their medical indemnity insurer when an issue arises. 

Make no mistake, good health records are imperative. Cases have been settled even though there was no negligence on the part of the medical practitioner because the health records were inadequate or unhelpful to the extent they impact adversely on the medical practitioner’s evidence. A court may prefer the evidence of a credible plaintiff who apparently has a very clear and persuasive recall of their personal matter over a practitioner’s evidence of what their likely advice would have been and their usual practice.

More reasons for keeping good records

Having poor or compromised health records may result in a case being settled because a medical practitioner’s credibility has been impaired by such records. 

Here are examples of how poor record keeping can result in complaints or claims:

  • Wrong medication prescription
  • Failure to follow up with an important test
  • A developing condition that is not treated appropriately
  • Relevant information, i.e. patient history, is  not included in a referral to a specialist
  • A condition is not diagnosed that creates inadequate requests to radiologists or pathologists
  • A subpar history is recorded that leads to a patient being unsuccessful in a claim for compensation against someone else
  • Illegible or wrongly comprehensible health records can lead to provision of inappropriate and/or harmful treatment by a medical practitioner and/or someone else treating the patient in reliance upon the records.

Tego Insurance offers Medical Indemnity Insurance and Medical Malpractice Insurance, as well as, Medical Practice Insurance, Doctors Indemnity Insurance, GP Medical Indemnity Insurance, and more. With our deep knowledge and understanding of the Australian medical profession and our constantly evolving healthcare system, we are able to provide leading cover with more innovations, choice, and greater flexibility. More importantly, we are also here to support our medical practitioners and help resolve any matters that may arise. 

If you are a medical practitioner with Tego, your medical indemnity insurance comes with 24/7 medico-legal advice and support to guide you through the risks that come with being an AHPRA registered doctor.

This publication is general in nature and is not comprehensive or constitutes legal or medical advice. You should seek legal, medical or other professional advice before relying on any content, and practice proper clinical decision making with regard to individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgment or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Tego Insurance Pty Ltd is not responsible to you or anyone else for any loss suffered in connection with the use of this information. 

All content on this page has been written in a generic way, and has not been presented with any knowledge of your personal objectives or financial needs.