Privacy and Confidentiality of your Medical Record

Privacy and Confidentiality of your Medical Record

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:

  • identify a person accurately
  • record symptoms and signs
  • support diagnosis
  • Justify management decisions.
  • Record all information fully and accurately including (but not limited to):
  • Medications
  • Allergies
  • Vaccinations
  • Cultural background
  • lifestyle risk factors
  • This practice uses an electronic file system
  • Medical records are integral to the provisions of effective ongoing care. This practice has an obligation to maintain records in a form that facilitates this.  All significant contacts with the patient, regardless of whether they are face-to-face or via the telephone will be recorded in the patient’s medical record.  This is to enhance continuity of care.
  • An alert notification for allergic responses and drug reactions is marked in the patient’s medical record.

Format of new health records

Computerised

  • Collect patient name, address, date of birth and related demographic details.
  • Enter information on the computer.
  • Inform the doctor that the patient is new

Content of health records

Practice procedure

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

  • adverse medicines events
  • current medicines list
  • current health problems
  • past health history
  • risk factors
  • immunisations
  • relevant family history
  • relevant social history.

Our practice also ensures that:

  • 90% of active health records contain a record of allergies in the health summary
  • significant face-to-face, telephone or electronic communication is recorded in the patient record
  • health records are updated to show recent important events including immunisations, births and family history changes
  • ‘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.

Consultation notes

Practice policy

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

Consultation must include the following:

  • date of consultation
  • reason for consultation
  • relevant clinical findings
  • diagnosis
  • recommended management plan and where appropriate expected process of review
  • prescribed medicine (including medicine name, strength, directions for use/dose frequency, number of repeats, and date medicine started/ceased/changed)
  • any relevant preventive care undertaken
  • documentation of referral to other health care providers or health service
  • any special advice or other instructions
  • identification of who conducted the consultation, e.g. by initial in the notes, or audit trail in electronic record
  • evidence that problems raised in previous consultations are followed up.

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:

  • the GP and clinical staff verbally informing patients at the time of request
  • the practice information sheet
  • a notice in the waiting area.

 

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:

  • scanning and/or recording digital images are a normal procedure for storing patient information for our practice
  • when the document or image was created, e.g. document or image is time and date stamped
  • who created the document or image and that this person was capable and responsible
  • there is a defined procedure for creating and checking electronic documents
  • the system that created the document or image was not susceptible to tampering or hacking (i.e. the document could not be edited)
  • audit logs are available to track access.

Practice procedure

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

Our scanning processes consist of the following steps:

Step Activity
1 Document is time and date stamped
2 Document is scanned and stamped with “Scanned”
3 Document is distributed to relevant Doctors
4 Scanned documents are disposed of once receipted by Doctor
5  

Make An Enquiry Today

Please be advised CQ Medicentre is offering for your convenience a new Southside location. We are located at City Centre Plaza, near the food court. Bulk billing is available at CQ Medicentre Southside for concession card holders and children under 16.
CQ Medicentre Northside (07) 49277 611

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