PRIVACY & RECORD MANAGEMENT POLICY
The practice further adheres to the Australian Privacy Principles, the Privacy Act 1988 and any state-specific laws.
We ensure that patient information is kept private, confidential and respected; where it will not be disclosed in any form (verbally, in writing, electronic forms and inside/outside our practice) except for strictly authorised use within the patient care context at our practice or as legally directed. All health records that are gathered by the practice are for the purpose of delivering and assisting in giving the utmost care and service to the patient, where it is further regarded as classified and confidential.
Computerised patient health information in the practice are kept secure at all times. We ensure that prescription pads, prescription computer generated paper, letterhead, scripts, medications, health records and related patient information are out of view. They are stored in areas only accessible to authorised persons. Facsimile, printers and other electronic communication devices are accessible to authorised staff only.
The privacy of the patient is greatly valued thus, it is not permitted by employees to discuss and disclose any patient health information to family, friends, staff or others without the patient’s consent. This information includes medical details, family information, address, employment and other demographic and accounts data.
The Practice acknowledges that patients may desire to acquire their medical records. Therefore, it is recommended and required that you provide this request in a written format, then the practice will attend and complete it within a just time period. Likewise, if you have personal information that you would like to update then please do not hesitate in contacting the practice to update it as well as providing it in writing.
Communication with patients via telephone and electronically is conducted with appropriate regard to the privacy and confidentiality of the patient and their health information.
When we receive telephone calls nurses and receptionists will try their utmost best in assisting the patient.
However, if a patient requires to speak to a doctor whilst they are in a consultation or are unavailable, a message will be recorded and will be forwarded to the doctor afterwards. The doctor will either contact the patient back or give staff direction in what to advise the patient regarding the written note.
If it is a matter of urgency, it will be triaged accordingly.
The practice has an email address that patients can utilise to send fundamental communication to the either the doctor or staff members. The emails are checked regularly and any email that is delivered will be given to the appointed individual as requested and will be kept in the patient’s record. Please do not use email to contact the practice in an emergency or for urgent matters, instead please call us and we will attend to your matter immediately.
Sensitive information such as, test results and prescriptions will only be sent by the practice team to the patient when consent is given by both the doctor and the patient. If you have not seen one of the doctors for the prescription and/or the test results you will need to book an appointment with them. Please do not hesitate in contacting the medical centre if you have any inquiries regarding this.
We aim to protect every patient’s information that is provided electronically, however it is important to remember that electronic communication can potentially be compromised and accessed by individuals outside of our practice. Patients that decide to communicate with Good Shepherd Medical Centre through email do so at their own risk.
PRESENCE OF A THIRD PARTY
At times, a third party may be requested to attend a consultation. Some reasons include:
- General Practitioner may feel more comfortable having a third party present
- During examination, such as the attendance of a nurse.
- General Practitioner registrar observing for training purposes
- Patient may be accompanied by a third person such as a carer or family member.
For each of the above reasons, consent must be obtained.
If a medical student or other person is observing, interviewing, or examining or education and training purposes, it is preferred that it is advised at the time of making an appointment, or when they arrive at reception.
Our practice collects written consent from patients for medical students and other persons receiving training by advising at the time of making an appointment, or when they arrive at reception.
Our practice collects consent from patients if they are accompanied by a third person into the consultation room by asking the patient if they wish to have the third-party person attend the consultation. (E.g. carer, workers compensation rehabilitation provider, family member)
PATIENT HEALTH RECORDS
All clinical contact with a patient is recorded electronically in Best Practice Premier within individual health records. All of our patient records are in an electronic file system. The patient health records contain all clinical information about the patient and includes;
- Identification (sex, cultural background, age, address, phone numbers, Medicare number etc.)
- Consultation progress notes
- Requests and results of investigations
- Health care plans
- Scanned documents from external sources (ie specialist reports/letters, paper based results, medicals)
Each patient file contains a health summary which can be printed out separately if required or can be included in a referral or a GP Management Plan.
The health summary includes:
- Current medicines list
- Current health problems
- Risk factors
- Past health history
- Relevant family history
Our General Practitioner, Nurses and Reception Staff ensure that all information pertaining to a patient is recorded in the patient’s health record through Best Practice Premier.
Our practice also ensures that:
- We keep an up-to-date record of allergies in the health summary
- Significant face-to-face, telephone or electronic communication is recorded in the patients record
- Health records are updated to show recent important events including immunisations, births, and family history changes
- Health records contain emergency contact details
- Self-identified cultural background is recorded in the patient’s health record from the new patient form
‘Active health records’ are considered to be records of a patient who has attended our practice 3 or more times in the past 2 years.
Each of our patient health records contains sufficient information about each consultation to allow another doctor to carry on the management of the patient.
Information is entered into the patient health record at the time of each consultation including after hours, home visits, and those via the telephone or as soon as information relating to the patient becomes available. This information includes the date of consultation, patient reason, relevant clinical findings, diagnosis, recommended management plan, any prescribed medicine, and relevant preventative care, documentation of any referral to other health care providers or health services, any special advice or other instructions and identification of who conducted the consultation.
All follow up information is also entered into the patient health record.
TRANSFER OF HEALTH RECORDS
On request by the patient, our practice transfers a summary or a copy of the patient health record to the patient, another medical practitioner, health service provider or health service.
Practice staff notifies our General Practitioner about all requests for patient health information. Our practice records the request on the health record, and this includes details as to the date, where and when the information was sent and who authorised the transfer.
The patient must provide written consent to the transfer. Our practice retains the original record and provides the new General Practitioner with a summary or a copy. If a summary of the patient’s health record is provided to the new General Practitioner, a copy of the summary is kept in the electronic file.
Our practice engages with a range of allied health professionals, disability service and community services to plan and manage care. Our referral documents to other health care providers contain sufficient information to facilitate optimal care. Our patients are made aware that patient health information is being disclosed in the referral documents.
Letters of referral are usually computer based and in the case of an emergency or other unusual circumstance, a telephone referral may be appropriate. Practice letterhead is used through Best Practice and all documentation is recorded in the patient’s health record.
Referral letters are created electronically in the patient’s health record. The referral includes a health summary of the patient.
Referral documents include; pathology request, medical imaging request, specialist consultancy, hospital services and various allied health care professionals.
Patients who telephone our practice requesting a referral staff firstly ask the patients if the doctor is aware of their specialist request before notifying the doctor to organise the referral. The patients are also advised of the 24-48 hour time limit for the doctors to write referrals and patients are asked to call the practice to check that their referral is ready for pick up.