Clinical records in the spotlight as prosecutions mount: six tips for good record keeping

A recent landmark case shows banal oversights may have a devastating impact: well-known Chinese herbalist, Dr Shuquan Liu, famous for helping Malcolm Turnbull lose weight, was found guilty of unsatisfactory professional conduct – the first case of its kind against a Chinese medicine practitioner in NSW – largely due to poor clinical record keeping.

The finding should resonate with any health or medical practitioner in Australia and is an interesting case study on how poor records leave you vulnerable to various claims and disciplinary prosecution.

The NSW Health Care Complaints Commission prosecuted Dr Liu based on a program of fasting, remedial massage and acupuncture he prescribed for a patient with chronic ulcerative colitis.

He was accused of using staff who weren’t registered or adequately skilled practitioners. However, the case largely hinged on his failure to record a complete case history and to maintain proper clinical records in accordance with the Chinese Medicine Board of Australia’s guidelines regarding the patient’s diagnosis, symptoms, diet, treatment plan and progress.

While this landmark case has garnered some attention as something of a novelty, it is not an isolated incident – we are seeing many cases where health and medical practitioners, such as doctors and dentists, are prosecuted due to inadequate medical records.

Practitioners are particularly vulnerable without good record keeping, because a disciplinary board or judge will often otherwise favour the complainant’s version of events – it’s commonly assumed the complainant has a stronger recall of events because they are dealing with a rare or even life-changing situation, while it’s possible that a medical practitioner’s memory is clouded from seeing large numbers of patients.

It can be years before a claim or complaint is determined. A practitioner may have seen dozens or even hundreds of patients by the time a complaint or proceeding is formally lodged and brought to their attention.

Can you accurately recount each treatment provided in the last three years? What if the treatment was provided by a staff member who left your practice years ago and is now overseas?

Poor record-keeping may be interpreted as indicative of sloppy behaviours more broadly, which may create a damaging impression if you’re defending several accusations and trying to convey professional integrity and competence. Conversely, clear and well-ordered records suggest high standards are maintained.

It is also the case that the various health practitioner boards set minimum standards in relation to clinical records (as was noted in the context of the disciplinary action against Dr Liu).

Without good record keeping, it’s easy to become lost during an investigation – a paper trail is essential to trace a patient’s case history including diagnosis and treatments. But how can medical and health practitioners be confident they have adequate records? They should at least contain the following:

• Client details (name and address)
• Date of each treatment or consultation
• History provided by the client
• Assessment undertaken and the findings on each assessment
• Treatment plan and estimated cost
• Information and advice provided to client, particularly relating to warnings regarding potential adverse outcomes
• Treatment provided
• Post-care instructions provided

Even with this list, potential grey areas and ambiguities may still emerge. Consider the following six tips for creating a quality paper-trail:

• Keep it clinical: The records must literally be clinical, without any personal or potentially offensive comments on the client. As a minimum, such comment could embarrass you, but if unveiled at a trial or hearing could cast doubt on your professionalism, adversely impacting the result. Treat your records as you would a personal interaction – if you would not say it to a patient’s face, avoid writing it down.
• Make it habitual: Impeccable clinical records usually come from a strong habit or routine – for example, you may consistently prepare your notes during a consultation, or immediately after, at the end of the day (from file notes taken at or as soon as possible after the consult) and so on. The best record-keepers follow a routine.
• Abbreviate wisely: If you use abbreviations then use them consistently. Try to use abbreviations commonly used by the profession or the public. Ensure abbreviations have a standard meaning throughout your practice, so staff are also using the same abbreviations.
• Ensure readability: Any handwritten notes need to be legible – if you can’t read them others will not be able to do so.
• Ensure ‘informed consent’ is present and properly handled: Informed consent is critical in defending complaints. Patients must be given sufficient information to make an informed decision whether to proceed with any proposed treatment. Practitioners need to cover:
  • The diagnosis made
  • What further investigations may be required
  • Treatment options available
  • Likely costs involved
  • Potential adverse outcomes

These must be communicated clearly, with minimum jargon, so the patient will understand.

Informed consent must be documented, with the client acknowledging they understand the issues and agree to the recommended action.

Acknowledgment in writing is best: some practices add an informed consent section to their standard admission form, which the client may sign once a decision is made; alternatively, you may have the client sign your clinical notes where you have documented the discussion.

• Don’t over-rely on standard forms: Your practice may have standard forms, which is a great start, but every case is different. The fact and context of your documentation is equally as important. Be careful when trying to fit a unique situation into a standard form, which may not adequately cover everything. When using a standard form, ensure they are filled out properly – gaps may suggest key items were overlooked.

A good paper trail will not prevent complaints being made, but will prove invaluable should you and your legal advisors ever need to defend a claim.