Best Practice Guidelines: Medical | Dental | Allieds

Responsible Role

	Operational Role: The practitioner is the only person legally allowed to complete and access clinical/medical information about the patient. Complete clinical Information to record the patient’s health information, treatments, and medications. The practitioner must legally maintain patient health records for no less than six years, depending on the speciality.
	Collection stage: Information quality Compliance continuity stage: Updated information Confidentiality measures

Purpose of Clinical Information

• Capturing clinical information will assist the practitioner in diagnosing the patient and ensure that an accurate history of each patient and the patient event is kept.
• When a patient requires further medical attention, medical records will assist the practitioner in making the correct diagnosis and applying the proper treatment.
• Updated Clinical information can be sent to other practitioners, for example, Specialists, to assist in further treatment.
• During legal proceedings between the patient and practitioner, clinical records can be helpful.
• We always say it never happened if it is not written down.
• All Clinical Forms will be saved under the patient Clinical History and can be viewed, printed or edited at any time.