Medical Records

Privacy and Confidentiality of your Medical Records

A copy of our medical record privacy and confidentiality policy can be obtained from our reception on request.

Patient health record systems

Practice policy

A medical record is a detailed, confidential document compiled by a health professional, over a period of time, on a particular person. Its primary purpose is to:

Format of new health records

Computerised

A medical record is a detailed, confidential document compiled by a health professional, over a period of time, on a particular person. Its primary purpose is to:

Content of health records

Practice procedure

Our practice ensures that at least 50% of active health records contain a health summary including:
Our practice also ensures that:

Consultation notes

Practice policy

Our practice documents all consultations including those outside normal opening hours, home or other visits and clinically significant telephone or electronic consultations.

Consultation must include the following:

Our patient health records show evidence that problems raised in previous consultations are followed up.

To ensure that quality consultations continue in the event of computer failure, our practice prints templates from the clinical software program and store in a central location. These can then be used as part of the consultation with hand written notes scanned with a notation in consultation notes indicating the location of hand written notes. Alternatively, hand written notes can be entered into the clinical software when the computers come online. This forms part of our practice’s Emergency responce plan.

Results, reports and clinical correspondence

Practice policy

All tests and results (including pathology results, diagnostic imaging reports, investigation reports and clinical correspondence received) are reviewed, signed or initialled (or the electronic equivalent), indicated with an action statement and acted on in a timely manner by the GP and incorporated into the patient health record.

Our practice has a system in place to follow up tests and results, reports and clinical correspondence where there is concern about the significance of the test or result. This also includes tests or referrals ordered for the patient. This forms part of our Recall and reminder system.

This system is managed by the GP and the practice nurse. It is however the GP’s responsibility to identify and flag patients of concern.

Results, reports and clinical correspondence must be reviewed and actioned by the GP prior to scanning.

Practice procedure

Our practice manages incoming pathology results, diagnostic imaging reports, investigation reports and clinical correspondence by computer link with the relevant testing organisation. For all paper results these are scanned and marked as entered after review by the GP.

Patients are advised of the results and other correspondence. This is by:

Scanning documents and digital images

Practice policy

As with computerised health records, the current legal position is that the original document is the best evidence. In the absence of an original document, the court has to be convinced that a copy is a true copy of the original and the person responsible for computerised records may be required to give details on what happened to the original document. In the case of images created using a digital camera, these images are the original document.

To be able to dispose of original documents once scanned and present an electronic document or digital image as evidence, it is necessary to prove:

Practice procedure

In our practice, we scan patient correspondence received into the patient’s electronic record.

Our scanning processes consist of the following steps: