Documentation of the care and treatment of a patient is fundamental to the practice of all healthcare professionals. This is particularly so for medical practitioners who, in the main, are directing the care and treatment of the patient via the medical records which serve as a vehicle by which to communicate with the other members of the healthcare team. A patient’s records (variously referred to as the ‘medical records’, the patient’s ‘health information’, ¹ or the patient’s ‘health records’²) may include not only the medical, nursing and research notes held by hospitals and other healthcare institutions or facilities but also those notes written at the pre-admission or post-discharge phases of care delivery. The purpose of the medical records is to facilitate an optimal patient outcome through the accurate, objective and contemporaneous description of the ongoing care. In addition to providing an account of the relevant patient information, the records serve as a method of communication from one health professional, or group of health professionals, to another. Patient records may also be used for research purposes, as educational tools and as documentary evidence in legal proceedings. For these reasons, it is imperative that medical practitioners understand the significance of the content of any patient’s medical records and the potential for the use of such documents. Entry of patient information into the medical records by a medical student must be consistent with their level of competency and the policies and guidelines of the institution in which they are undertaking their clinical practicum. Entries into a patient’s medical records by medical students must also be consistent with, and in response to, the delegation of this activity by the supervising clinician.

The content of a patient’s medical records depends not only on the particular care and treatment the patient received, but also on the particular institution or healthcare facility which has created and maintained the documents. As stated by Queensland Health and quoted in Field: ³

Medical practitioners have both professional and ethical responsibilities to create and maintain accurate records in relation to the treatment and care given to patients. For example, the Australian Medical Association Code of Ethics requires that doctors ‘[m]aintain accurate contemporaneous clinical records’. ⁴

There is no Commonwealth legislation mandating the recording of patient or client information by health professionals or facilities. At the state level the recently repealed Medical Practice Regulations 2008 (NSW) mandate that a medical practitioner or medical corporation must ‘make and keep’ a medical record, ⁵ and the Health Services (Private Hospitals and Day Procedures Centres) Regulations 2002 (Vic) regulations 21 and 22 provide that a proprietor of a private hospital or day procedure centre must commence a clinical record ‘as soon as practicable after the admission’ and maintain that record over the period of the patient’s stay in the facility. Regulation 22 identifies information, such as the patient’s name, address, date of birth, sex and unit record number, details of relatives or friends nominated as contact persons and the relevant clinical details which are to be included in the clinical records. While there are no specific legal requirements as to the formatting of medical records, the policy provisions of the employing healthcare institution, and the case law, provide guidelines as to the particular information which should be included in the patient records. Dix et al suggest that while the ‘form and content’ of medical records created by private practitioners continues to be at the discretion of the particular provider, there is a trend towards a more uniform approach to record-keeping. ⁶

The following are factors to be considered when recording information in relation to the care and treatment of a patient.

In the case of McCabe v Auburn District Hospital, ⁸ the deceased was admitted for an emergency appendicectomy. Post-operatively, his condition was poor and deteriorating. He was spiking a temperature, sweating, complaining of severe abdominal pain, unable to keep fluids down and suffering with diarrhoea. On the fifth day post-operatively, the medical practitioner ordered a full blood count. This was undertaken and the results, which showed a high white cell count and other abnormalities indicative of a severe infection, were forwarded to the ward the same day. As it was the weekend, the medical practitioner, though ‘on call’, had left the hospital. The registered nurse receiving the results proceeded to file them in the incorrect section of the medical records and neither notified the medical practitioner nor raised the findings with the nurses on the next shift. The pathology results were not discovered until two days after they had been received in the ward. The patient later died from peritonitis.

The deceased’s mother brought an action against the hospital and the hospital staff alleging negligence. In upholding her claim, his Honour made the following comments: ⁹

It is not acceptable to go back and add information to the medical records once the medical practitioner becomes aware that litigation has been initiated. Often such an addition may be inaccurate due to the passage of time or, where accurate, is not considered as a contemporaneous record of what actually occurred at the time of the patient contact. In institutions or practices where the patient records are computerised, there is often an ‘audit trail’ which will identify when the entry was made. The inclusion of handwriting experts in the pre-trial stage has also increased the possibility of additions and alterations to the patient notes being detected. A finding that a medical record has been altered will obviously have a detrimental impact on the testimony of a medical practitioner who has given sworn evidence that the documentation was contemporaneous. Where the medical practitioner wishes to make an addition to the records it is acceptable to do so by clearly indicating, through the inclusion of the date and time of the entry, that the addition or amendment was made. For example, giving the date and time of the actual entry and then commencing with the prior date and approximate time the medical practitioner became aware of the information or made the actual observation. The issue of taking and maintaining thorough and complete medical records was raised in Locher v Turner¹¹ and Vale v Ho. ¹² In Locher’s case, the medical practitioner had failed to order or carry out investigative procedures on a female patient who presented with rectal bleeding. Over the 12 months between the initial consultation and a diagnosis of carcinoma of the sigmoid colon with metastases in the liver, the plaintiff had consulted the doctor on a number of occasions. The parties were in dispute as to whether, on these occasions, the patient had referred to the continuation of the rectal bleeding. The medical records did not thoroughly outline or detail the progress of the patient’s condition. The Court of Appeal therefore held that as there were no adequate contemporaneous notes recorded then neither the evidence of the doctor nor the patient could be taken as correct. In contrast, Vale’s case involved a doctor who had recorded extensive and detailed notes regarding his patient. The patient had undergone plastic and reconstructive surgery to his nose. His Honour, Judge Sinclair, when confronted with different versions of the events by the parties, preferred the medical evidence as it was consistent with the contemporaneous notes which had detailed the care that the patient had received.