Health practitioners should only collect health information about patients with their informed consent. It is usually reasonable to assume that consent is implied if the information is collected/recorded from details provided by the patient during a consultation – as long as it is clear the patient understands what information is being recorded and why.
It is vital to ensure that record keeping is thorough and accurate, both to ensure the best possible ongoing treatment of the patient and to comply with good clinical practice.
Ahpra (Australian Health Practitioner Regulation Agency) has guidelines that outline healthcare practitioners’ patient record obligations:
- Records must be accurate, up-to-date, factual and legible.
- They must be objective and show respect for patients, be non-judgemental and not include remarks that may be interpreted as prejudiced, demeaning, derogatory, discriminatory, racist or culturally unsafe.
- They must include all relevant clinical history, diagnostic, treatment and services information, and advice and include correspondence with other treating practitioners. If you’re not sure, refer to your code of conduct or use our self-reflective tool.
- Records should clearly identify the date and time that the service was provided, as well as who provided the service and, when relevant, where the service was provided.
- They should document informed consent for treatment, examinations and services provided. You may need to include written consent for some procedures that are considered higher risk or that may result in serious injury or death.
The Ahpra guidelines are available online at Australian Health Practitioner Regulation Agency – Managing health records (ahpra.gov.au).
