Clinical Records

Policy

See Medical Council of New Zealand: Managing patient records for more information.

Clinical records are integral to the management and continuity of good patient care. They are useful for auditing, and provide evidence to support a clinician if concerns over care are raised. Clinicians must write a clinical record at the time of the consultation, or as soon as possible afterwards.

We use an electronic patient management system to securely store patient records in accordance with the Health Information Privacy Code 2020. All clinical information is reliably backed up and password protected. If an AI medical scribe tool is being used to assist clinical note taking, we obtain and document patient consent and follow the guidelines in our Generative AI policy.

See also IT Security, Generative AI, and Care Plans.

To enable continuity of care with other healthcare providers, patient records provide a permanent, clear, and complete account of patient care.

Patients may request access to their own records.

In certain situations patient records may need to be disclosed to third parties, such as other health providers or government agencies.

Patient notes are accurate and objective in line with best practice. All services provided to a patient are added to their patient record.

Patient records are updated by the clinician treating the patient at the time of consultation, or as soon as possible afterwards. Clinicians review any new patient records received within 10 working days.

Health information is retained for a minimum of 10 years from the date of last consultation.

See also Safeguarding Patient Information and Transferring Patient Records.

Adding information to patient records

Patient records should permanently document any information relevant to a patient's healthcare.

All clinical records are:

• respectful and non-judgemental
• accurately dated
• capable of identifying the clinician who wrote them
• easy to understand – including using only approved abbreviations
• sufficient for follow-up by other practitioners.

Corrections or additions to a patient's clinical record must be initialled and dated by the clinician making them. However, amendments should not involve deleting or substantially changing earlier entries.

Patient records may also include photos, audio, or video recordings. Clinicians must have permission from the patient before taking a photograph or recording a clinical interaction, and should let the patient know they can request a copy of either.

Clinical records may be audited as part of a clinician's continuing professional development. RNZCGP have an optional Nurses Clinical Record Self-Audit Form and Clinical Record Review Self-Audit Checklist available.

Arms Act