New guidelines for patient health records

16 Aug 2016

Following wide consultation, the Chinese Medicine Board (the Board) today published new guidelines for creating and maintaining health records.

Chinese medicine practitioners need to know and understand Guidelines: Patient health records to ensure their practices meet National Board expectations.

‘These guidelines aim to assist practitioners to practise Chinese medicine safely and support the Board’s effort to facilitate public access to safe health services. Proper patient health records serve the best interests of patients by ensuring patient safety and continuity of care,’ Chinese Medicine Board of Australia Chair, Professor Charlie Xue, said.

‘When exercising professional judgment related to each individual patient, practitioners must maintain their records in accordance with the guidelines. These guidelines prescribe the expected minimum standard.’

In developing the guidelines, the Board gave careful consideration to:

  • patient safety issues
  • the purpose of patient records
  • the context of grandparenting, and
  • that all registered practitioners are required to keep certain minimum information in English

The Board recognises guidelines need to be practical and implementable in order to achieve compliance. For the Chinese medicine profession, the guidelines mean records should be kept entirely in English, with the exception of practitioners registered with English language conditions under grandparenting provisions1. These practitioners must, however, keep certain information in English, for example, patient identity and up to date emergency contact details. The Board respects the historical background of Chinese medicine however patient safety is paramount. The Board has revised the guidelines to ensure there is an adequate balance between public safety and workforce requirements.

Chinese medicine practitioners are also expected to comply with the nomenclature requirements in the Board’s Guidelines for safe Chinese herbal medicine practice.

FAQ and additional information

Summary of key changes

Existing Guideline  Revised Guideline 
Title: Guidelines for Patient Records  Title: Guidelines: Patient health records 
  • Allowing the keeping of records in languages other than English was only to apply to those registered under the ‘grandparenting provisions’
  • Those grandparented (registered) Chinese medicine practitioners who submitted evidence that they met the National Board’s English language registration standard were expected to record their health records in English.
  • This concession is now limited to those who have English-language conditions of registration.
  • This is supported by the sections titled ’Language of health records’ and ‘Translation of health records’.
  • This guideline is also supported by the recently published Guidelines for safe Chinese herbal medicine practice which address nomenclature for safe prescribing, labelling and dispensing.
  • Information critical to patient safety, such as herbal names should be recorded in the most competent language e.g. English, Chinese, Latin, other.
    Certain minimum information must be kept in English by all registered practitioners. For example:
    • Any patient health record should contain sufficient and reasonable information, in English, to adequately identify and manage the patient2.
    • Up-to-date contact details, in English, of the person to be contacted in an emergency.

    1Transitional arrangements from 1 July 2012 to 30 June 2015 for registering existing practitioners under section 303 of the National Law.

    2For example, full name, date of birth, gender and contact details, (and patient’s parent or guardian where applicable).  

     
     
    Page reviewed 16/08/2016