Extract from Health Practitioner Regulation (NSW) Regulation 2010 - PART 4
7 Records relating to patients
(1) A medical practitioner or medical corporation must, in accordance with this Part and Schedule 2, make and keep a record, or ensure that a record is made and kept, for each patient of the medical practitioner or medical
corporation.
(2) A contravention of subsection (1) by a medical practitioner does not constitute an offence but may constitute behaviour for which health, conduct or performance action may be taken.
(3) Subclause (1) does not apply to the following:
(a) a public health organisation within the meaning of the Health
Services Act 1997,
(b) a private health facility within the meaning of the Private Health
Facilities Act 2007,
(c) a nursing home within the meaning of the Public Health Act
1991.
(4) Subclause (3) does not affect the application of subclause (1) to a medical practitioner appointed, employed, contracted or otherwise engaged by a medical corporation referred to in subclause (3).
8 Medical services corporation to appoint practitioner to be responsible for record keeping
(1) A medical corporation must, by written notice given to the Medical Council, appoint a medical practitioner to be responsible for record keeping by the corporation. There must be such an appointment in force at all times, otherwise the medical corporation is guilty of an offence.
Maximum penalty: 2 penalty units.
(2) The notice of appointment must be accompanied by a notice of acceptance of the appointment signed by the appointed person.
(3) An appointment may be revoked by written notice given to the Medical Council given either by the corporation or by or on behalf of the appointed person. The appointment is automatically revoked if the person appointed ceases to be a medical practitioner.
(4) If a medical corporation contravenes this Part or Schedule 2, the person appointed under this section to be responsible for record keeping by the corporation at the time of the contravention is taken to have contravened
the provision that the corporation contravened.
9 When records are to be made
(1) A record must be made contemporaneously with the provision of the medical treatment or other medical service or as soon as practicable afterwards.
(2) This clause may be complied with by the making of further entries in a single record that relates to the patient concerned.
10 How long records are to be kept
(1) A record must be kept for at least 7 years from the date of last entry in the record, unless the patient was less than 18 years old at the date of last entry in the record.
(2) If the patient was less than 18 years old at the date of last entry in the record, the record must be kept until the patient attains or would have attained the age of 25 years.
(3) In this clause: date of last entry in the record means the date the patient concerned was last provided with medical treatment or other medical services by the medical practitioner or medical corporation who provided that
treatment or those services.
11 Disposal of medical practice
(1) If a medical practitioner or medical corporation disposes of a medical practice, the practitioner or corporation is taken to have complied with clause 10 if the practitioner or corporation makes reasonable efforts to ensure the records are kept in accordance with that clause.
(2) In this clause: reasonable efforts include:
(a) providing the records to the medical practitioner or medical corporation that acquires the medical practice, or
(b) providing the records to the patient to whom they relate.
12 Storage
(1) All reasonable steps must be taken to ensure that all records are kept in such a manner as to preserve the confidentiality of the information that is contained in them and to prevent them from being damaged, lost or
stolen.
(2) Despite subclause (1), a record must be reasonably accessible for the purpose of treating the patient to whom it relates.
Extract from Health Practitioner Regulation (NSW) Regulation 2010 SCHED 2 - RECORDS KEPT BY MEDICAL PRACTITIONERS AND MEDICAL CORPORATIONS IN RELATION TO PATIENTS
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 services 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 proposed by the medical practitioner who is treating the patient.
(4) A record must include the following particulars of any medical treatment (including any medical or surgical procedure) 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 medical treatment (including any medical or surgical procedure) proposed by the medical practitioner who treats the patient must be kept as part of the record relating to that
patient.
2 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.
3 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.
4 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.
5 Delegation
If a person is provided with medical treatment or other medical services 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.
