Medical record issues in claims

What are the main issues raised in member claims in relation to medical records. Find out the underlying themes across all specialties and insights to reduce your risk of these types of claims, in our analysis.

Monday, 24 February 2025

Overview

Practice points

Claims with poor medical records were more likely not to meet the expected standard of care compared to those with good records.
The main issue was inadequate and/or incomplete information.
Medical record issues were seen most in medication-related claims, particularly those involving drugs of dependence. These were also commonly observed in diagnosis-related claims regarding the initial assessment stage of care.

Records should convey adequate and complete information to ensure safe and effective ongoing care of the patient.
Document clinical features that demonstrate the reasoning behind a diagnosis, particular test or prescription.
Document significant negative history and examination features in your clinical notes.
Good records assist in the defence of a claim or complaint against you.
For information on the key requirements of medical records, check out our factsheet, Medical records: the essentials.

^{All data is based on Avant claims and complaints closed from 1 July 2019 to 30 July 2024.}

Medical record issues identified in 1 out of 5 claims

In the majority of claims where medical records were identified as an issue, records were found to be inadequate or incomplete. For example:

not documenting important verbal discussions about risks of complications or treatment options
omitting details about physical examinations, tests or treatments performed
not documenting negative history or findings, and diagnosis considered but ruled out.

Graph showing inadequate/incomplete (86%), inaccurate (9%), no record(s) of consultation(s) (3%), records inappropriately altered by member/other provider/staff (3%), illegible (2%) and other (2%).

^{(Each claim may have more than one allegation about medical records.)}

Medical record issues are often identified in claims about medication and diagnosis

Most of the medication-related claims identified involved prescribing drugs of dependence.
The diagnosis-related claims identified primarily concerned the initial assessment stage, with inadequate examination and failure to refer for diagnostic testing among the allegations.

Graph highlighting that medical record issues were noted in claims about medication (26%), diagnosis (22%), management/treatment (20%), procedural/surgical (15%) and practitioner behaviour (12%).

Poor medical records can compromise the outcome of a claim

Our analysis indicates a significant relationship between the quality of medical records and the outcome of a claim. Those with poor records were more likely to be assessed as below standard on the main issue than claims with good records.*
Claims could not be defended in some cases due to incomplete or missing records.
Complaints to regulators resulted in more severe outcomes when records were found to be poor.

^{*Statistically significant relationship between the two variables based on chi-square test of independence, X2 (1, N=14205) =1051.78, p is less than .01.}

Two pie charts side-by-side. One pie chart describing claims assessed as below standard on the main issue was comprised of 29% claims with poor records and 71% with claims where records were not a concern or met the standard. The other pie chart describing claims assessed as meeting the standard on the main issue was comprised of 8% claims with poor records and 92% claims where records were not a concern or met the standard.

^{(% of complaints/claims where the assessment of the expected standards on the main factor is known. Cases with 'poor records' are those where the quality of medical records were considered 'below standard'.)}

About this analysis

This report is based on our analysis of the underlying themes in nearly 16,000 claims for Avant member doctors from all specialties, including complaints to regulators and compensation claims finalised between 1 July 2019 and 30 June 2024.

Analysis of claims with medical record issues was based on claims and complaints with an issue in the standard of documentation of medical records as the primary or secondary allegation. Medical record issues in claims may be raised by a patient, identified by a regulator or identified by Avant during the claims process.

More information

If you receive a claim or complaint, contact us on 1800 128 268 for expert medico-legal advice- available 24/7 in emergencies.

Avant’s Risk Advisory Service provides personalised support to help proactively reduce your exposure to claims. You can benefit from a personalised risk assessment with a focus on strategy to improve your medical records. Contact us at Risk.Advisory@avant.org.au or visit Risk Advisory Services - Avant.

For any queries on this analysis, please contact us at research@avant.org.au.

Visit our Insights & Resources page for further educational content including webinars, eLearning courses, case studies, articles and factsheets.

IMPORTANT: Avant routinely codes information collected in the course of assisting member doctors in medico-legal matters into a standardised, deidentified dataset. This retrospective analysis was conducted using this dataset. The findings represent the experience of these doctors in the period of time specified, which may not reflect the experience of all doctors in Australia. This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision-making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published [February 2025].