Epilepsy and the law-medical records

This paper reviews the need to keep medical records and concludes that Section 126 of the New South Wales Medical Practice Act, 1992, requires such provision to comply with adequate "professional conduct". This was above and beyond other possible mandatory maintenance of appropriate records, such as may be covered by the notifiable diseases provisions of the Public Health Act. Ethical codes of conduct imposed further obligations to maintain appropriate records, and legal defence against claims of misconduct or negligence required documented evidence to refute false accusations. The emphasis of records has changed with greater need to stipulate risk exposure associated with proposed treatments and advice provided for such things as necessary follow-up. It was further shown that appointment diaries, extra file entries and indications of any failed attendance and resultant subsequent actions were all part of adequate record-keeping. Finally, the paper reviews ownership of medical records and refers to the New South Wales case of Ms Breen, in which it was found that ownership of records, as at the printing of this paper, resided with the doctor.