A recent landmark case shows how simple oversights may have a devastating impact: well-known Chinese herbalist, Dr Shuquan Liu, famous for helping Malcolm Turnbull lose weight, was found guilty of unsatisfactory professional conduct, largely due to poor clinical record keeping.

The finding should resonate with any health or medical practitioner in Australia and is an interesting case study on how poor records leave practitioners vulnerable to claims and disciplinary action.

The NSW Health Care Complaints Commission prosecuted Dr Liu regarding a program of fasting, remedial massage and acupuncture which he prescribed for a patient with chronic ulcerative colitis.

He was accused of using staff who weren’t registered or adequately skilled practitioners. But the case largely hinged on his failure to record a complete case history and to maintain proper clinical records complying with the Chinese Medicine Board of Australia’s guidelines regarding the patient’s diagnosis, symptoms, diet, treatment plan and progress.

Practitioners are particularly vulnerable without good record-keeping, because a disciplinary board or judge will often favour the complainant’s version of events – it’s commonly assumed the complainant has a stronger recall of events because they are dealing with a rare or even life-changing situation, while it’s possible that a medical practitioner’s memory is clouded from seeing large numbers of patients.

Poor record-keeping may be interpreted as indicative of sloppy behaviours more broadly, which may create a damaging impression. Conversely, clear and well-ordered records suggest high standards are maintained.  It is also the case that the various health practitioner boards set minimum standards in relation to clinical records (as was noted in the context of the disciplinary action against Dr Liu).

Health Care Complaints Commission v Liu [2017] NSWCATOD 18

Health practitioners are increasingly vulnerable to prosecution if they can’t produce a quality paper-trail.

While this landmark case has garnered some attention as something of a novelty, it is not an isolated incident – we are seeing many cases where health and medical practitioners, such as doctors and dentists, are prosecuted due to inadequate medical records.