Noteworthy Outcomes of a Medical Record-Keeping Workshop

Participants at MDA National’s education workshops are planning to change the way they manage medical records.

Our Noteworthy: The How, What, Where and Why of Medical Documentation activity focuses on areas that have been identified as being problematic for doctors in recent court and Medical Board findings, and in MDA National Members’ queries.

An average of 80% of respondents in the first 11 sessions delivered across Australia said they were considering doing something differently because of the activity.

Here are the main areas in which participants intended to make changes:

1. Obtain consent before releasing information to others:

• Ensure there is a signed authority from the patient. Exceptions to this include a court order to produce documents. Contact the patient if unsure whether they understood what they were consenting to.
• A patient’s right to confidentiality does not cease when they die. Seek consent from the executor or administrator of the deceased patient’s estate.¹
• Correspondence from third parties forms part of the medical record, which means you do not need permission from the author. When releasing a specialist’s letter to a third party you can let the author know out of professional courtesy, if you wish to do so.

2. Review storage security: 

• Store paper records in an area that can be locked.
• Regularly change passwords and do not share them.
• Maintain appropriate levels of access, e.g. do not allow support staff to log on as a doctor.
• Perform regular backups of the database and test the backup system. The interval period between backups will dictate the minimum amount of data that cannot be recovered in the event of data loss.²

3. Be more thorough:

• Use SOAP to structure consultation notes³ :
  • Subjective – presenting complaint and history
  • Objective – examination findings and investigation results
  • Assessment – diagnoses, differential diagnoses and problem lists
  • Plan – all aspects of management discussed during the consultation and follow-up instructions.
• Document the essential elements of phone calls including who, when, and what was discussed with the patient, other doctors and allied health professionals. Note that the discussion occurred over the phone, not face-to-face. If phone contact was attempted but not successful, that should also be recorded.
• There is no ‘universal’ right or wrong information that needs to be recorded for an informed consent conversation. It is generally agreed that you should note the patient’s decision, details of the health care to be provided, the benefits and risks discussed, and the date and time.

For further and specific advice on medical records, contact MDA National.

Want to experience the Noteworthy activity for yourself?

Go to mdanational.com.au/Member-Services/Education to find upcoming events on the calendar or to request a session.

You can also do an online version whenever convenient. Find out more and access it at: bit.ly/2nQ6yGM

MDA National Education Services

References

1. MDA National. Defence Update. Access to Deceased Patients' Records. Available at: defenceupdate.mdanational.com.au/articles/access-deceased-patient-records
2. MDA National. Defence Update. Security of Electronic Records. Available at: defenceupdate.mdanational.com.au/articles/security-of-electronic-records.
3. Physician SOAP Notes. [cited 20 August 2018]; Available at: physiciansoapnotes.com.