Medical records: what to keep and for how long
Under the Private Healthcare Facilities and Services (Medical Record and Information) Regulations 2012, a clinical record must be accurate, contemporaneous and retained — and an amendment must preserve the original entry rather than replace it.
Amend, never overwrite
This is the rule that shapes everything else. A note that can be silently changed proves nothing about what was known and decided at the time. When a note is amended, the original must survive, marked, with both authors and both timestamps visible.
This protects the doctor at least as much as the patient. A complete, unaltered record with a visible correction is a much stronger position than a tidy record nobody can vouch for.
Retention
Records must be retained, and the period differs by record type and by patient circumstances — a paediatric record is not treated like an adult one. Because the rules differ and change, Klinira does not delete clinical records at all; it retains them and lets the clinic decide, with advice, when anything may be disposed of.
Access, and the audit of it
Who may see a record is as much part of record keeping as what is in it. Klinira audits views as well as changes, per named user and per workstation, so the question “who opened this file” has an answer.
The patient's copy
A clinic must be able to produce a patient's record when it is properly requested. This is one reason Klinira never gates the export function behind licence state: a lapsed subscription must not stand between a clinic and its statutory duty.
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