Medical records: what you need to know

This collection includes our educational resources on medical records, designed to support you in understanding and meeting your responsibilities. Explore guidance on documentation, privacy, access, and retention to help ensure compliance and best practice in managing medical records.

Holding slid medical records insights

Documentation and AI

In our webinar on AI technology, we discussed how AI scribes can help clinicians generate clinical documentation.  Further information and guidance on navigating AI can be found in our collection page. 

Watch webinar
Resources

Documentation

Learn the key principles of documentation like how to structure a record and what to include. 

Medical records: the essentialsMedical certificates: your responsibilityRural GP reprimanded over shortcuts and skipping steps

Access and privacy

Find out how to manage requests for medical records while protecting patient privacy.

Responding to a request to access medical recordsDeceased patients and their medical recordsProviding patient information to police - is it okay?Are you allowed to look at that medical record?

Record managment

Understand your responsibilities for appropriate record management to ensure compliance. 

Storing, retaining and disposing of medical recordsHarsh penalties for unauthorised access to medical recordsGP deregistered after altering records

Real cases

Discover real-world examples of privacy breaches and documentation issues.

GP reprimanded and ordered to pay $455,00 for Medicare billing breachesSkin clinic breached privacy laws for failing to provide patient accessSurgeon’s documentation found to be below standardTragic case illustrates risks of informal consultations and unstructured handover

Avant medical records eLearning

Improve your documentation and medico-legal knowledge with our interactive eLearning courses.  These Avant member only modules cover essential aspects of medical record-keeping, legal requirements and best practices for referrals and specialist letters.

Medical records: part one - documentation
Medical records: part two - managing medical records
Medical records: part three - handwritten or EMR activity

What happens when you need our support?

If you require general medico-legal advice, members can contact our Medico-legal Advisory Service.

Medico-legal Advisory Service