Submission: Ahpra Guidelines for clinical records

Guidelines for clinical records 

The existing Guidelines for clinical records were first published in 2012 and are due for review. The current guidelines give guidance to practitioners on their requirements regarding patient health records, setting out a minimum standard for record making, but noting that practitioners are expected to use professional judgement in deciding what to record on an individual basis. 

Our feedback

Key points from our feedback include:

• When the guidelines were developed, they were useful, however, more appropriate resources now exist and we agreed with the Osteopathy Board's recommendation to retire the guidelines. 
• The content is covered in more current codes or guidelines. In addition, Osteopathy Australia's website contains information about clinical records and informed patient consent. 
• It is inconsistent with other National Boards. The Ahpra health records management resources are more user-friendly, appropriate and consistent with other professions.
• The guidelines in their current form do not contain information about how long to keep clinical records, and there is no advice or information on what to do if a practitioner has been subpoenaed to proide clinical records in court. 
• We agreed with the Osteopathy Board's position to retire the guidelines, particularly considering that there are no unique professional requirements for osteopaths that are not covered within the contemporary shared Code of conduct and the shared resources for managing health records. 

Our submission

You can read our full submission here.