Report on performance
Scenario 10
Service claimed
MBS item 23 - Professional attendance involving taking a selective history, examination of the patient with implementation of a management plan in relation to one or more problems.
Record entry
Transcript of part of the discussion with the practitioner reads:
Committee Member --- but what is the purpose of keeping the clinical records?
Practitioner Well, it's basically just a matter of keeping records so that you can jog your own memory, as such. I more or less just use the notes as - well, you know, you know more about your own patients than any other doctor, that's for sure. So, you know, they would be stuff I'd carry around in my head, obviously, and, you know, there would be - the notes - the notes are - as I say, in terms of my protocol, obviously, you know, history, eye contact, examination and a happy patient is sort of my first and utmost thing that I'm looking at to do, and then, you know, the record keeping is sort of like a necessary evil, from my point of view. You know, it's necessary, but, you know, who likes sitting there writing voluminous notes about nothing?
I'm not going to record every - everything I've heard, and every blood pressure I've taken, and every pulse rate because there's - simply the time constraints, you know, in a bulk billing practice don't allow that sort of situation.
If I was probably living in a more - in an area that was of a higher socio-economic level, and I had more time to take notes, then I would, but, you know, I found that a happy patient was a better outcome from the end of a consultation. And the notes - notes are obviously important.
Committee Member Okay. And you also told me, I think, that there's a difference in the level - depending on the patient's economic status, whether they're disadvantaged or not disadvantaged, that might determine the quality of your documentation. Could you explain that to me a little?
Practitioner Well, obviously, if I was just privately billing rich patients, and I was seeing like 20 or 30 patients a day, then, obviously, I'd have a lot more time and, you know, I could do a lot more documentation.