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How long should Medical Records be kept and why?

Newsletter Article 03 June 2009

This is a particularly vexing question for doctors who have limited space in their rooms and given the cost of storage.  The problem is exacerbated as doctors approach retiring age.

The situation in New South Wales is governed by the Medical Practice Regulation 2008.  Regulation 6 provides:

  1. ‘a record must be kept for at least 7 years from the date of last entry in the record, unless a patient was less than 18 years old at the time of the last entry in the record;
  2. if the patient was less than 18 years 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;
  3. in this clause:

date of last entry in a record means the date the patient concerned was last provided with medical treatment or other medical services by the registered medical practitioner or medical corporation and provided that treatment for those services’.

Essentially, in New South Wales, the law requires a patient to bring a claim against a doctor within 3 years of suffering damage from some act or omission by that doctor.  In general this time does not commence to run if the patient is under a disability such as a minor.  This perhaps explains the rationale behind Medical Practice Regulation 6(2).

A maxim espoused by medical defence organisations for many years is ‘no notes, no defence’.  A busy doctor is likely to consult thousands of patients in his/her professional career.  It is unreasonable to expect that one would remember particular patients during that period except in extraordinary circumstances.  In an ideal world, medical records would be kept for the duration of a doctor’s career then perhaps not culled until well after retirement or perhaps after death.

However, this creates a number or practical difficulties.  Are the medical records placed in permanent storage just in case.  Who pays the costs?  Is there any taxation relief?

The alternative is to store the records at home if facilities permit.  What happens if the family home is finally sold and there is no more space?

The answer probably lies in downloading the records in electronic form and then destroying the hard copies.


Don Munro, Partner
Sydney

Newsletter Article 03 June 2009
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