New South Wales Repealed Regulations

This legislation has been repealed.

MEDICAL PRACTICE REGULATION 1998 - SCHEDULE 2

SCHEDULE 2 – Records relating to patients

(Clause 13)

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:

(a) any information known to the medical practitioner who provides the medical treatment or other medical services to the patient that are relevant to his or her diagnosis or treatment (eg 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), and

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

(c) any plan of treatment for the patient, and

(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 registered 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 registered medical practitioner who is treating the patient:

(a) the date of the treatment,

(b) the nature of the treatment,

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

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

(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 any medical treatment (including any medical or surgical procedure) proposed by the registered 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 registered 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) Abbreviations and short hand expressions may be used in a record only if they are 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 registered medical practitioner or medical corporation must not alter a record, or cause or permit another person to alter a record, in such a manner as to obliterate, obscure or render 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 registered 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 registered 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 registered medical practitioner ensures that the record is made and kept in accordance with this Schedule.