Best Practice Guidelines: Healthcare Practice Management

Best Practice Guidelines: Healthcare Practice Management

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7. Clinical information

Responsible Role

The practitioner is the only person who is legally allowed to complete and access clinical/medical information about the patient.

Clinical Information will be completed by the medical practitioner to keep a record of the patient’s health information, treatments, and/or medications that are used or will be used. The practitioner is legally bound to keep patient health records for a period of no less than 6 years.

Purpose of Clinical Information

  • Capturing of clinical information will assist the practitioner in diagnosing the patient and ensure that an accurate history is kept of each patient and patient event.
  • When a patient requires further medical attention medical records will assist the practitioner in making the correct diagnosis and applying the right treatment.
  • During the course of legal proceedings between the patient and practitioner clinical records can be helpful.
  • We always say if it is not written down, it never happened.

By following the Clinical Information diagram you will sufficiently capture all of the clinical/medical information that is necessary to successfully fulfill your role as a practitioner.

The following sub chapters will provide details pertaining to each segment in the diagram.