Medical practitioners who receive a claim or complaint notification will often be asked by the insurer for a copy of the health records. The notification may in fact have been prompted by a request by the patient or their solicitor for a copy of their records.

The issues that face a practitioner who has inadequate records of the clinical management of a patient are in three main areas:

  • Difficulty defending claims.
  • Difficulty refuting complaints of inadequate clinical management or unprofessional conduct.
  • Difficulty in justifying fees.

It is not a definitive statement but there is a lot of truth in the saying:

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

Tego Insurance Is Here To Help

We are experts in medical indemnity insurance and medical malpractice insurance which typically include cover for dealing with and responding to complaints. 

Make no mistake, good health records are imperative. Cases have been settled even though there was no negligence because the health records were inadequate or unhelpful to the extent they impact adversely on the 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 (invariable) practice.

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Altered or Compromised Health Records 

Altered or compromised health records mean that a case may have to be settled because of the impact this may have on a practitioner’s credibility and the risk to their reputation of a public finding. 

Poor record keeping can be a cause of complaints and claims. For example:

  • failure to follow up a test.
  • prescription of wrong medication.
  • a developing condition is not recognised and treated appropriately.
  • a condition is not recognised/diagnosed, e.g. inadequate request to a radiologist/pathologist.
  • relevant information, i.e. patient history, is  not included in a referral to a specialist.
  • a poorly recorded history given by a patient may lead to a patient being unsuccessful in a claim for compensation against someone else, such as their employer, i.e. lack of corroboration of the circumstances of an injury.
  • misreading (illegible or wrongly comprehensible) health records can lead to provision of inappropriate and/or harmful treatment by you and/or someone else treating the patient in reliance upon your 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 transitioning healthcare system, we are able to provide leading cover with more innovations, choice, and greater scalability. Contact us to find out more.

This publication is general in nature and is not comprehensive or constitute 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.