Records, files and reports

Frequently asked questions

How should I store records and data, and can I use the Cloud?
What should be in clinical records?
How long should I keep patient records?
A physiotherapist is not keeping proper records. What can I do?
Should I keep clinical notes for a Group and a Class?
A patient has asked for their medical records. Can I provide them?
Can I charge for providing a patient access to their records?
Can I charge lawyers or other companies for providing records?
A third party, like a private health insurer, wants to see clinical records. What should I do?
have received a subpoena to produce my clinical records. What should I do?
Can I claim expenses for attending Court or giving evidence?
Who do patient files belong to?
Can I charge for writing a report?

How should I store records and data, and can I use the Cloud?

You should ensure any method of storage meets the requirements of the Privacy Act. You may use the cloud to store data - the Privacy Commissioner provides guidance on storing data in the Cloud.

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What should be in clinical records?

  • Clinical records must contain sufficient information to allow a physiotherapist of similar skill to continue the treatment of that patient if required.
  • All abbreviations, terminology and symbols recorded in the clinical record should be recognisable by physiotherapy peers.
  • Physiotherapists must accurately document all consultations.
  • Records must document each attendance and be completed as soon as practicable after treatment.
  • Clinical records must be dated, and if appropriate, include the time of the consultation.
  • They must be legible and signed by the treating physiotherapist with the physiotherapist’s name clearly printed.
  • Where a service is provided by a physiotherapy student, the records must be countersigned by the supervising physiotherapist.

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How long should I keep patient records?

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.

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.

The 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.

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A physiotherapist is not keeping proper records. What can I do?

A physiotherapist must keep accurate records. The Physiotherapy Board of Australia code of conduct sets out requirements.

Furthermore physiotherapists must retain clinical records for a minimum period of seven years from the date the last entry was made for consumers 18 years of age or more, and for consumers under 18 years of age, seven years from the date the consumer turns 18.

The APA can contact a member to remind them of their obligations. You can also notify AHPRA, or the Health Care Complaints Commission (HCCC) if you are in NSW or the Office of the Health Ombudsman (OHO) if you are in Queensland to discuss whether it is a matter they should investigate.

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Should I keep clinical notes for a Group and a Class?

Yes. Clinical records must be kept for participants in groups and classes, with sufficient notes on each patient’s file.

Notes must be accurate and clinically justify the interventions provided to the client, as well as anything else of significance to the patient’s progress to date and clinical goals. Refer to the APA Position Statement on ‘Health Records’.

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A patient has asked for their medical records. Can I provide them?

The Australian Privacy Principles and other state and territory legislation regulate information gathered and held by organisations, and Australian Government (and Norfolk Island Government) agencies (see: resources for health service providers).

The Privacy Principles require you to provide access to a patient’s health information without unreasonable delay or expense, and give access to the information in the manner requested by the individual, if it is reasonable and practicable to do so.

If medical records are held by a private sector organisation, like a physiotherapist in private practice or by a private hospital, as a general rule, patients have a right to gain access to all the information held about them. If the medical records are held by a Commonwealth agency, patients also have a right to access those records, unless the agency is required or authorised to refuse access to that information under the Freedom of Information Act 1982 or another Commonwealth law.

A patient may:

  • look over the records
  • take a copy of those records
  • have them explained
  • have information corrected if it is wrong

There are some limitations on the right of access. These may apply, for example, to:

  • where giving access would pose a serious threat to the life and health of anyone
  • where refusing access is required by law

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Can I charge for providing a patient access to their records?

You are not required to charge a patient for access and you should consider whether it is reasonable, fair or good service in the circumstances. The Australian Privacy Principles state that you may charge for providing a patient access to their records, unless you are a government agency. The charge must be reasonable. You must not charge someone for asking for their records or for correcting information. However, state and territory legislation may differ. For example, Victoria has maximum fees . In all cases, any fee should be reasonable.

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Can I charge lawyers or other companies for providing records?

You may charge companies, including lawyers, for providing copies of patient records. You should contact the third party requesting the records to discuss what you intend to charge. Some government entities, or entities with which you may have a contractual obligation to provide information, like insurance companies, may not pay for information.

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A third party, like a private health insurer, wants to see clinical records. What should I do?

You should seek written consent from the patient. You could get consent by letter or email, or when the patient joins your practice.

The third party (e.g. private health insurer) should provide sufficient notice to get patients’ consent and make necessary arrangements for inspection e.g. retrieving files, setting up an area to inspect the files.

The patient has a right to deny consent but the patient accepts the risk that, if they deny consent, the third party (for example a Private Health or workers compensation insurer) may refuse to pay for a service.

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I have received a subpoena to produce my clinical records. What should I do?

You may receive a subpoena to produce your clinical records to a Court of Law or the police. A subpoena is a legal document and you must comply with a subpoena request and the conditions, for example to produce records “from 15 July 2013 to 12 May 2014 only”. You should also consider seeking legal advice.

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Can I claim expenses for attending Court or giving evidence?

The Court does not pay witnesses for pre-trial phone conferences or for attendance as expert witness.

However, you are entitled to be compensated for costs and loss of earnings which you have incurred as a result of coming to Court. You should discuss in advance compensation with the person or lawyer who has called you to give evidence.

You may be compensated for:

  • any cost of travelling to and from the Court;
  • the cost of overnight accommodation (if necessary);
  • a reasonable amount to compensate you for any wages or income you may lose when you attend the Court; and
  • if you are an expert witness, payment for the time you have spent preparing a report

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Who do patient files belong to?

While the physical written patient files belong to the practice, a patient has a right to see the files, and to have those files, or copies of those files, transferred to another practitioner on their request without unreasonable delay.

Depending on any contractual arrangements, patient files do not belong to individual practitioners within a practice. You may not take the patient files with you after you cease employment, unless stated in a contract. In a case where you bring patient files to a practice, you should negotiate a prior agreement and write up a contract that specifically covers that you will take the files you originally brought into the practice when you leave. You should always have a contract in writing.

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Can I charge for writing a report?

You can charge by the hour for writing a report, for example to a solicitor or compensable body. Charges should be reasonable. You should discuss fees or compensation with the person or authority that has requested information. Some bodies, like tribunals, may not compensate you for providing evidence but you may be required by law to provide that evidence. Other entities may have fixed amounts for compensation.

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