Patient records – The why, who, what, where, and when


Most people working in an Aboriginal health service (and any other health facility) will identify with the suggestion that you can ask 10 different people the following questions:

  • Who should record in the patient record?
  • What should be recorded?
  • How should it be recorded?
  • When should it be recorded?

You will often end up with 10 different answers for every question – and you could quite possibly get different answers from the same person depending on the day. The ‘why do we record in patient records?’ is less challenging although nonetheless inconsistency is still found.

Answers to the why? can range from: ‘medico-legal reasons’, ‘continuity of care’, ‘it’s a requirement of accreditation’, ‘it’s the policy of this health service’, ‘we need it for data collection’, ‘it’s a contract requirement’. Of course, all of these answers are correct, yet none seem to be sufficient in assisting to understand the principles enough to translate to consistent, good practice.

This module attempts to demystify the patient records debate. It offers practical guidance on who should create a patient record, when it should be created, and where the record should be documented. The module is NOT about patient privacy and a separate module is available on patient privacy.

This module is aimed at all those who create patient records – doctors, Aboriginal health practitioners and workers, nurses, midwives, drivers, allied health practitioners, counsellors, program workers, receptionists, environmental health workers and anyone else in the AMS providing client care

Learning Objectives

At the end of this module participants will be able to:

  • Know why patient records are created.
  • Know what the elements are of a good medical record.
  • Know who should create a patient record.
  • Know what should be included in a patient record.
  • Know what should not be included in a patient record.
  • Know when a patient record should be created.
  • Explain to colleagues the reasons for creation of any particular record.

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