Data Saved to the Permanent Record
Power Diary permanently saves all communication to a client’s permanent record with only a few exceptions. The exceptions relate to circumstances where the content is not typically classified as being part of formal health or medical records such as bulk emailed practice newsletters or automatic SMS and Email appointments reminders. These types of communication are saved for 12 months by default. However if needed any correspondence can be marked for permanent retention. For example, if the receipt of a practice newsletter triggers a discussion in a therapeutic session, the clinician may decide to add the newsletter to the permanent record.
Correspondence Automatically Saved Permanently
- All letters
- All manually sent emails i.e. not bulk sent
- All manually sent SMS including all messages sent via the SMS Panel
- All uploaded files and documents
Correspondence Saved for 12 months:
- Automatic SMS and email appointment reminders
- Bulk sent SMS/emails
- Bulk SMS sent from your Waitlist
You can still save these types of correspondence to the Permanent Record at any time within 12 months - just toggle the Save to Permanent Record option.
It is important to note that whilst the actual content of the reminder message is not retained after 12 months, the fact that a reminder message was sent is recorded in each appointments’ log with an entry like this:
“12/09/2021 9:10 AM Sms sent to Julie Ester confirming appt on Tue 14 Sep at 10:30AM”
Don’t I need to save all records?
Health practitioners have a professional, legal and ethical obligation to keep detailed medical and health records for each patient they provide services to. This ensures there is an accurate record of the health services and treatments provided to a patient, as well as ensures current and future treatment plans are documented which enables continuity of care should a practitioner be incapacitated due to unforeseen circumstances.
“Maintaining clear and accurate medical records is essential for the continuing good care of patients”... and involves... “Keeping accurate, up to date and legible records that report relevant details of clinical history, clinical findings, investigations, diagnosis, information given to patients, medication, referral and other management in a form that can be understood by other health practitioners.” (Code of Conduct - AHPRA: Medical Board)
Whilst most direct contact or correspondence between practitioners and patients form part of a formal health or medical record, many purely administrative contacts may not. Consider whether a health practice would reasonably be expected to record and retain as part of the formal medical record the following types of administrative interactions:
- Patient phones and advises administrative staff they may be 5 mins late for appointment.
- Patient phones to ask the receptionist if the practice accepts Amex for payment.
- Patient attends the front desk and books appointment for next week
- Patient phones to confirm if GP has faxed their referral yet.
- Patient leaves a voicemail confirming they are coming to tomorrow’s appointment
In most cases it is unlikely that such contacts would be recorded as they are a routine part of health practice administration. However, if the administrative contact were to become relevant from a clinical perspective then the practice may likely opt to make a formal record of this, i.e. if a patient was uncharacteristically aggressive and demanding. Failing circumstances such as this, routine administrative contact is typically recorded nor retained.
As the UK NHS Records Management Code of Practice (2021) puts it:
“Transactional messages, such as GP appointment reminders or pharmacy notifications that your prescription is ready for collection, have a short shelf-life and will no longer be needed once the appointment is attended or prescriptions collected. Organisations that use these systems should keep a record of messages sent to a person, in case they are needed later (such as proof that the patient was reminded of their appointment), but once it is clear that the purpose of the message has been fulfilled, there is no requirement to keep these messages.”
Why save administrative or marketing correspondence at all?
Whilst we know many practice management platforms do not save this type of correspondence, or only saves them for a short period (i.e. 7 - 30 Days), we think saving for 12 months better ensures the messages are not needed clinically and Practitioners can therefore be confident that such records are not relevant to the patient’s health or medical record and can be safely discarded.
Shouldn’t we just save all system generated records just to be safe?
No. As tempting as that might initially sound it can result in practical and legal problems as follows:
- Clarity of the medical record
Health records are required to contain clear, succinct, relevant information about a patient’s past, current and future treatment in the form of clinical notes, test results, referrals, and professional correspondence. The inclusion and long-term retention of records related to routine or automatic administrative activities can adversely impact the ease and speed in which important and relevant clinical information can be located.
- Interoperability and Transportability
The legislative direction of medical record management increasingly calls for enhanced levels of interoperability and transferability between systems. As such practice management systems should not routinely retain excessive records and rely on internal controls to highlight what is clinically relevant as such controls are unlikely to be available to users viewing the records via an alternative system.
- Retention Justification
Health record management is a complex and changing area as requirements, expectations and technology evolve. As always we follow developments in this space closely and will continue to build tools to support practitioners and health administrators in the best ways we can.
The above is an explanation of how Power Diary handles certain types of content and the reasons for this. This is not legal advice.