A clinical record is health information under the Privacy Act 1988 (Cth), a document under the uniform evidence legislation, and material that can be subpoenaed, produced to Ahpra, read at a coronial inquest and tendered in a civil claim years after the consultation. That status does not depend on the software the entry was written in, or on who produced the first version of it.
The statutory basis
The Privacy Act 1988 (Cth) classifies health information as sensitive information. Victoria, New South Wales and the Australian Capital Territory each add a health-records statute setting a minimum period for which a private health record has to be kept.
The uniform evidence legislation defines a document widely enough to cover anything from which sounds or images can be reproduced, so audio and transcripts sit alongside the typed entry.
The Medical Board of Australia's code of conduct requires records that are accurate, up to date and legible, and that report the clinical history, the findings, the investigations, the information given to the patient and the management. Inadequate record keeping can be dealt with as unsatisfactory professional performance.
Elements of a defensible entry
A note made during or immediately after the encounter is evidence of what was known at the time, and a time stamp shows the gap between consultation and entry.
The entry names who saw the patient, who wrote it and who signed it, and separates the clinician's own findings from history given by a family member or another practitioner.
A defensible entry carries the reasoning: the differentials considered, the findings that pointed away from them, the advice given, and the safety-netting.
Amendments and addenda
A correction goes in as a dated, attributed addendum stating what changed and when. Overwriting or deleting the original leaves a metadata trail showing an edit occurred.
Where the record system keeps every version and logs who changed what and when, the amendment is provable from the system.
The unsigned draft
An unsigned draft is not the clinical record. The record is the entry the treating clinician reviewed and signed.
A draft is still health information under privacy law and a document under the evidence legislation, so a practice that holds one can be required to produce it.
Where a superseded draft is retained and differs from the signed entry, both can be produced and the difference is the clinician's to explain. Where drafts are discarded at signature, nothing survives to compare. The retention configuration decides which applies.
The record in aurii
aurii drafts the note and the correspondence. aurii does not write into practice management software, so the signed entry is filed by the practice in its own clinical record.
The treating clinician remains responsible for the clinical content. Clinical safety.
Every action a practice user takes is written to a hash-chained audit log. How the chain works.
This article is general information about clinical records and Australian law. It is not legal advice for a particular practice.