New South Wales Consolidated Regulations

HEALTH PRACTITIONER REGULATION (NEW SOUTH WALES) REGULATION 2016 - SCHEDULE 4

SCHEDULE 4 – Records kept by medical practitioners and medical corporations in relation to patients

(Clauses 6(1) and 7(4))

1 Information to be included in record

(1) A record must contain sufficient information to identify the patient to whom it relates.

(2) A record must include the following--

(a) any information known to the medical practitioner who provides the medical treatment or other medical service to the patient that is relevant to the patient's diagnosis or treatment (for example, information concerning the patient's medical history, the results of any physical examination of the patient, information obtained concerning the patient's mental state, the results of any tests performed on the patient and information concerning allergies or other factors that may require special consideration when treating the patient),

(b) particulars of any clinical opinion reached by the medical practitioner,

(c) any plan of treatment for the patient,

(d) particulars of any medication prescribed for the patient.

(3) The record must include notes as to information or advice given to the patient in relation to any medical treatment or other medical service proposed by the medical practitioner who is treating the patient.

(4) A record must include the following particulars of any medical treatment or other medical service that is given to or performed on the patient by the medical practitioner who is treating the patient--

(a) the date of the treatment,

(b) the nature of the treatment,

(c) the name of any person who gave or performed the treatment,

(d) the type of anaesthetic, if any, given to the patient,

(e) the tissues, if any, sent to pathology,

(f) the results or findings made in relation to the treatment.

(5) Any written consent given by a patient to a medical treatment or other medical service proposed by the medical practitioner who treats the patient must be kept as part of the record relating to that patient.

2 Record of partners of patients being treated for chlamydia

(1) A reference in this Schedule and clause 6(1) of this Regulation to a patient includes a reference to a partner of the patient if the patient is being treated for chlamydia and that treatment includes the patient and the partner being prescribed or supplied azithromycin for the treatment of chlamydia. For that purpose, the name and email address or mobile phone number of the partner is sufficient information to identify the partner.

(2) In this clause--

"partner" of a patient includes any of the following--

(a) the patient's spouse,

(b) the patient's de facto partner,

(c) a person with whom the patient is or was in a sexual relationship.

3 General requirements as to content

(1) In general, the level of detail contained in a record must be appropriate to the patient's case and to the medical practice concerned.

(2) A record must include sufficient information concerning the patient's case to allow another medical practitioner to continue management of the patient's case.

(3) All entries in the record must be accurate statements of fact or statements of clinical judgment.

4 Form of records

(1) An abbreviation or shorthand expression may be used in a record only if the abbreviation or expression is generally understood in the medical profession in the context of the patient's case or generally understood in the broader medical community.

(2) Each entry in a record must be dated and must identify clearly the person who made the entry.

(3) A record may be made and kept in the form of a computer database or other electronic form, but only if it is capable of being printed on paper.

5 Alteration and correction of records

A medical practitioner or medical corporation must not alter a record, or cause or permit another person to alter a record, in a way that obliterates, obscures or renders illegible information that is already contained in the record.

6 Delegation

If a person is provided with a medical treatment or other medical service by a medical practitioner in a hospital, the function of making and keeping a record in respect of the patient may be delegated to a person other than the medical practitioner, but only if--

(a) the record is made and kept in accordance with the rules and protocols of the hospital, and

(b) the medical practitioner ensures the record is made and kept in accordance with this Schedule.