Guidelines for patient record management on the discontinuation of practice

Guidelines for patient record management on the discontinuation of practice

“Medical records” and patient health information are broad terms, encompassing a range of data including
consultation notes, correspondence, referrals, investigations and results, photographs, video footage and
appointment records. Whether paper-based or electronic, when a practice closes due to retirement or
change in location, how the patient medical records are managed is subject to legal, regulatory and
professional standards.
Different jurisdictions have specific legislation governing the management of medical records. Due to the
complex and often overlapping nature of these legislative requirements, Fellows, members and diplomates
of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) are
advised to contact their medical defence organisation and/or the Australian Medical Association (AMA) or
the New Zealand Medical Association (NZMA) as appropriate, for information regarding the recommended
procedures to follow on the discontinuation of practice and management of patient records.
In addition to legislative requirements, relevant non-legislative regulation including the Medical Board of
Australia’s Code of Conduct1 (the Code) and the New Zealand Medical Council’s Maintenance and
retention of patient records2 provides specific guidance where the responsibilities of medical records
management are placed personally on individual medical practitioners and duties of corporate medical
practice entities. These standards advise careful health information management at all times, particularly at
practice closure. According to the Code, when closing or relocating your practice, good medical practice
involves
• Giving advance notice to patients where this is possible
• Facilitating arrangements for the continuing medical care of your patients, including the transfer or
appropriate management of patient records. You must follow the law governing health records in
your jurisdiction.1
The most stringent laws governing health information specific to practice closures are in the NSW3, 4, ACT5
and Victoria6, where a notice must be published in a daily newspaper and other practicable steps must be
taken to inform patients of the practice closure, such as placing signage in the practice, sending letters to
patients or advising patients when they attend a consultation.
7 Medical records can be transferred to either
the patient’s nominated practitioner or directly to the patient. Alternatively, if the practitioner intends to
retain and store the medical records, the patient should be advised as to how they can access their medical
records in the future.
Any medical records which have not been passed onto the patient or another practitioner must be stored
securely for the statutory period. This minimum period being for
• An adult – seven years from the date of last entry
• A child – until the age of 25 years.3-6
RANZCOG considers these stringent requirements to be appropriate in all Australian and New Zealand
contexts.
From a medico-legal perspective, medical records should be kept until such time as there is little or no risk
of litigation arising from the patient’s treatment. Unfortunately it is difficult to be definitive about the
applicable limitation period as courts have the discretion to extend in certain circumstances. Where there
has been a patient complaint, adverse outcome or the commencement of legal proceedings is likely, the
medical records should be kept indefinitely.

Guidelines for patient record management on the discontinuation of practice
WPI 8
3
Disposal of medical records must be done in a manner that preserves the privacy of the patient. The notice
of intent to destroy medical records, methods of disposal and development of a register to identify the
patient, period of time and date of disposal, vary amongst jurisdictions.
When a clinician decides to discontinue practice, the responsibilities regarding patient continuity of care and
the requirements for medical record management, transfer, storage or disposal are significant. In the event
that health records are not transferred to an identified practice, jurisdictional legislation is enforceable and
must be complied with. Although clinicians are no longer subject to regulatory and professional standards
upon relinquishing their medical registration, it is expected that, even upon retirement, the Medical Code of
Conduct is still followed.
Any agreement made should be in a form that is legally binding. It should include the provisions for access
by the relinquishing practitioner.


Waypoint

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