Safe Management of your Medical Records

Secure management of patients' health information is a major responsibility of a doctor who must take all reasonable steps to ensure that records are protected from theft, loss and unauthorised use, as these incidents have serious consequences. There are situations where managing medical records can become a challenge. Following some simple rules, may make life easier for a lot of medical practitioners.

There are some general rules:

• Records must be kept for seven years after the last consultation.
• If the patient is under 18 years of age the records must be kept until they turn 25.
• After these periods of time the records can be securely disposed if the doctor wishes to do so.

Some Challenging Scenarios

When a doctor retires there are a number of options available to him/her. Records can be retained in a storage facility or passed directly onto the patient or to another medical practitioner. The same principles apply if the doctor decides to sell or close his practice. There is no legal obligation for a medical practitioner to transfer medical records but it could be said there is an ethical one. As mentioned above, a suit can surface at any time. Defence of a claim becomes much harder if there are no records.

If a doctor dies, medical records become the responsibility of their legal representative. It is always wise to plan ahead about the management of medical records, for example have an agreement with another doctor so the records can be easily passed on.

When planning to sell, close or retire from practice, doctors must:

• Publish a notice in the local newspaper;
• Consider publication in a non-English newspaper if, the majority of patients are of the same ethnicity and do not have English as a first language;
• Display a notice in the waiting room;
• Notify in writing any patient receiving prolonged treatment.

Notices must be published two months before closure.

Lost or stolen records

All care needs to be taken to ensure that records are not lost or stolen which could lead to a complaint to the Privacy Commissioner. If storage protocols were found wanting, there could be serious consequences. If records are lost or stolen, doctors must:

• Notify the patients involved.
• Review storage and access protocols to minimize the risk of further loss or theft.
• Consider notifying the police.

Conclusion

In summary, records should be kept long term, if not indefinitely, to assist your medical indemnity provider to defend the unexpected claim. At Invivo we are committed to defending claims where there is no negligence. This will be of benefit to all our insured doctors in the long term as a reputation for defending claims will lead to fewer claims and reduced premiums.

For more detail on the Act's mentioned in this article please refer to the websites http://www.dms.dpc.vic.gov.au or http://www.legislation.nsw.gov.au

Molly Aftab
Insurance Officer
Invivo Medical Indemnity