What happens when your Council or Board raises a concern about your clinical records?

A clinical records concern from your Council or Board in New Zealand is a question about whether your notes are accurate, complete, written at the time and safe for the next practitioner to rely on. It can be the whole notification, or one part of a wider concern about care. Your records will be read in a competence review, by a Professional Conduct Committee or by the Health Practitioners Disciplinary Tribunal. Do three things now. Never alter, add to or annotate any record about the matter once the concern is raised. Get copies of the records through your employer or practice, and get advice from your indemnity insurer, your professional association or union, or a lawyer before you write to anyone. Then build evidence that your record-keeping has changed: an audit, supervision and completed remediation with dated certificates.

What a records concern is

Under the Health Practitioners Competence Assurance Act 2003 (the HPCA Act) your responsible authority can look at your records on any of its routes: competence, health or conduct. A records concern takes one or more of these forms.

• Missing notes. A consultation, a phone call, a result reviewed or a consent discussion with no entry at all.
• Late entries. An entry written hours or days after the event that does not say when it was written or why it was late.
• Amendments. A change to an entry after the event, whether to correct it or to improve it, without a visible note of what changed, when and why.
• Notes that do not match what happened. An entry that records an examination, a discussion or advice that the patient, a colleague or another record says did not take place.
• Copied notes. Text carried forward from an earlier consultation or a template that does not describe the consultation it sits in.
• Notes another practitioner cannot follow. No plan, no reason for a decision, no record of what the patient was told or agreed to.

A records concern can arrive on its own, from an employer or a colleague. It can also come to light while the authority is looking at something else, such as a complaint about care that went first to the Health and Disability Commissioner. The guide to how an HDC complaint reaches your Council or Board explains that route.

What your records are measured against

Every Council and Board sets a standard for records in its code of conduct or standards of practice: accurate, made at the time or as close to it as possible, legible, dated, attributable to you, and enough for another practitioner to continue care. The standard is the one for your profession and your scope of practice; the guide to what the Medical Council measures a doctor against and the guide to the Nursing Council's Code of Conduct show how a standard is applied to an allegation.

The law sits behind the standard. The Health Information Privacy Code 2020, issued under the Privacy Act 2020, sets the rules for how health information is collected, stored, used, disclosed and corrected, including keeping it secure and letting a patient see it and ask for it to be corrected. The Health (Retention of Health Information) Regulations require providers to keep health records for a minimum period. The Code of Health and Disability Services Consumers' Rights gives patients the right to information and to make an informed choice and give informed consent, and the record is where a provider shows that those rights were respected. Together these mean that a clinical record is a document the patient can see, other practitioners rely on, and your authority can ask for.

How a competence review or a Professional Conduct Committee reads your notes

A competence review under section 36 of the HPCA Act reads a sample of your records against the standard for your scope. The reviewers ask whether a practitioner who picked up the record could continue care safely, whether the reasoning for each decision is visible, and whether the record matches what you tell them in interview. A review is not confined to the records named in the concern; the reviewers can look at a wider sample to see whether the problem is one consultation or a pattern.

A Professional Conduct Committee reads records as evidence of what happened and of whether your account can be trusted. The difference between the two matters. An incomplete record is a question of competence, and it can be put right with supervision, audit and remediation. A record changed after the event to look better is a question of honesty, and the Committee and the Tribunal treat it as one of the gravest concerns a practitioner can face. The guide to an honesty or probity concern explains why.

Electronic record systems log when each entry was created, viewed and changed, and by whom. The authority can ask your employer or practice for that log. Any change made after the concern was raised will be visible, with its date, time and user.

What happens step by step

1. The concern is raised. The authority writes to you naming the records, the period and the route it has put the matter on, with a date for your response.
2. The records are gathered. The authority asks you, your employer or your practice for copies, and can ask for the electronic audit log as well.
3. You respond. With your adviser, you set out what the records show, what they do not show, what fell short of the standard and what you have changed since.
4. The authority decides the route. It can close the matter, counsel you, order a competence review, or refer the matter to a Professional Conduct Committee where honesty or a pattern of poor care is in question.
5. The review or investigation runs. Reviewers or the Committee read the records, can interview you and others, and can ask for a wider sample.
6. The outcome is decided. The authority or the Committee decides what follows, from no further action to a charge before the Tribunal.

The guide to what happens after a notification to your Council or Board sets out the routes in full, and the Council and Board investigation process explained shows each stage on one page.

What you can do now

• Get advice before anything else. Your indemnity insurer, your professional association or union, or a lawyer: for doctors the Medical Protection Society, for nurses NZNO, for midwives NZCOM. Tell them the date in the letter.
• Request copies in writing. Ask your employer or practice for the records named in the concern, and ask your adviser whether the audit log will help you show when each entry was made.
• Read the records as a reviewer will. For each entry named, write down what the record shows and what it does not show. Do not fill the gaps with what you think must have happened.
• Keep memory and record apart. In your response, label what comes from the record and what comes from your recollection, and say how confident you are in each.
• Change how you keep records from today. For new consultations, make entries at the time, date and sign them, and mark any late entry as late with the time it was written. This applies to new care only, never to the records under review.
• Arrange an audit of your own notes. A supervisor or colleague reviews a sample of your new records against the standard, and you keep the results with the date.
• Complete remediation before the response goes. Dated certificates attached to the response are evidence; a course promised is not.

The guide to writing a response to a notification sets out the structure of the response itself.

The outcomes

• No further action. Where the records meet the standard, or the gap was minor and you have shown what you have changed.
• Counselling or advice. The authority sets out its expectations and closes the matter.
• A competence programme or conditions on your scope of practice. After a review, the authority can require a programme, supervision or a regular audit of your records, and can set conditions until the programme is complete.
• Interim suspension or conditions. Where a Professional Conduct Committee is investigating, section 69 lets the authority suspend you or set conditions while the investigation is open if it considers that necessary to protect the public.
• A charge before the Tribunal. Where records were falsified or the failures were serious, a Committee can lay a charge. The guide to a Health Practitioners Disciplinary Tribunal hearing explains the penalties, which include censure, a fine, conditions, suspension for up to three years and cancellation of registration.

Where remediation fits

A records concern asks two questions: whether your notes now meet the standard, and whether you understand why it matters that they do. Documentation for Healthcare Professionals covers what a clinical record must contain and the legal and professional duties behind it. Insight for Fitness to Practise covers how to show an authority that you understand the risk a poor record creates for the next practitioner and the patient. Remediation for Fitness to Practise covers how to build the plan that brings the audit, the supervision and the certificates together; the guide to showing insight and building a remediation plan explains what goes in it.

Each course is NZ$200, takes 2 CPD hours, is self-paced with immediate access, and ends with a dated certificate issued by Healthcare Ethics Courses that you can submit to your Council or Board or put in your remediation plan. The remediation courses for every Council and Board are on the hub page. Profession guides describe what the Medical Council does after a notification about a doctor and what the Nursing Council does after a notification about a nurse.

Sources and further reading

• New Zealand Legislation: the Health Practitioners Competence Assurance Act 2003, the Privacy Act 2020 and the Health (Retention of Health Information) Regulations.
• Office of the Privacy Commissioner: the Health Information Privacy Code 2020 and its rules on storing, correcting and disclosing health information.
• Health and Disability Commissioner: the Code of Health and Disability Services Consumers' Rights, including the rights to information and informed consent.

Frequently asked questions

Can I correct a mistake I have found in my notes now that a concern has been raised?

No. Once a concern is raised, leave every record about the matter exactly as it is. Electronic systems log each change with the date, time and user, and a change made after the concern reads as an attempt to improve the record, which turns a competence question into an honesty question. Put the correction in your written response instead: say what the record shows, what you believe is wrong with it, and how confident you are.

What if my notes were written late?

Say so plainly in your response. State when the entry was made, why it was late and whether it was marked as a late entry at the time. A late entry that was labelled as late is a different matter from one presented as if it were written at the time. Then show what you have changed so that entries for new care are made at the time, with evidence such as a dated audit of your recent records.

Will the authority look at records beyond the ones named in the concern?

It can. A competence review reads a sample of your records against the standard for your scope, and the reviewers can widen that sample to see whether a problem is a single consultation or a pattern. A Professional Conduct Committee can also ask for further records and the audit log. Prepare on the basis that any of your records may be read, and make sure every new entry from today meets the standard.

Is a records concern a competence matter or a conduct matter?

It depends on what the records show. Missing, thin or late notes are a question of competence, and an authority can deal with them through a competence review, a programme, supervision or an audit. A record that was changed after the event, or that describes something that did not happen, raises a question of honesty and can go to a Professional Conduct Committee and, from there, to the Health Practitioners Disciplinary Tribunal.

What evidence shows that my record-keeping has changed?

Evidence the authority can check. A dated audit of a sample of your recent records by a supervisor or colleague, with the results. A note of what you changed in how you work, such as making entries during the consultation. Dated certificates for courses completed before your response goes. A written reflection on why the gap mattered for the patient and the next practitioner. A promise to change, without these, does not carry weight.