Common practice scenarios - what would you do?

8.4 Medical/health records

Maintaining clear and accurate medical records is essential for the continuing good care of patients. Good medical practice involves:

1. Keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.
2. Ensuring that your medical records are held securely and are not subject to unauthorised access.
3. Ensuring that your medical records show respect for your patients and do not include demeaning or derogatory remarks.
4. Ensuring that the records are sufficient to facilitate continuity of patient care.
5. Making records at the time of the events, or as soon as possible afterwards.
6. Recognising patients’ right to access information contained in their medical records and facilitating that access.
7. Promptly facilitating the transfer of health information when requested by the patient.

3.4 Confidentiality and privacy

Patients have a right to expect that doctors and their staff will hold information about them in confidence, unless release of information is required by law or public interest considerations. Good medical practice involves:

1. Treating information about patients as confidential.
2. Appropriately sharing information about patients for their health care, consistent with privacy law and professional guidelines about confidentiality.
3. Using consent processes, including forms if required, for the release and exchange of health information.
4. Being aware that there are complex issues related to genetic information and seeking appropriate advice about disclosure of such information.
5. Ensuring that your use of social media is consistent with your ethical and legal obligations to protect patient confidentiality and privacy.

8.2 Professional boundaries

Professional boundaries are integral to a good doctor–patient relationship. They promote good care for patients and protect both parties. Good medical practice involves:

1. Maintaining professional boundaries.
2. Never using your professional position to establish or pursue a sexual, exploitative or other inappropriate relationship with anybody under your care. This includes those close to the patient, such as their carer, guardian or spouse or the parent of a child patient. Specific guidelines on sexual boundaries have been developed by the Medical Board of Australia under the National Law.
3. Avoiding expressing your personal beliefs to your patients in ways that exploit their vulnerability or that are likely to cause them distress.

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