Professional, ethical and legal frameworks: scope of practice, regulation, documentation and accountability
This domain tests applied knowledge of New Zealand law and professional standards. Questions often hinge on what a record must contain or what to do when care falls outside your scope.
Frameworks
- HPCA Act 2003: registration, scope of practice, competence, recertification and mandatory notification.
- Midwifery Council standards and code of conduct.
- HDC Code of Health and Disability Services Consumers' Rights.
- Privacy Act 2020 and Health Information Privacy Code 2020.
- Care of Children Act 2004 for guardianship.
- Ethical principles: autonomy, beneficence, non-maleficence and justice.
Documentation
- Contemporaneous, objective and accurate; record discussions, consent, advice and actions.
- Late entries marked as late, signed and dated.
- Retention: 10 years from last entry for adults; for children until age 21.
- Keep records of text messages and telehealth advice.
Scope and accountability
- Work within scope; consult or refer when outside it.
- Prescribe only within authorised medicines.
- Manage conflicts of interest and professional boundaries.
- Report concerns about another practitioner under mandatory notification obligations.
Worked example
A record says "uncooperative". Better: "At 14:00 declined vaginal examination after discussion; reason X; plan Y." Objective records support care and are legally defensible.
Traps
Altering records; vague entries; assuming privacy can be waived verbally.