Personal Health Information
Your medical records are a confidential document. It is the policy this practice to maintain security of personal health information at all times and to ensure that this information is only available to authorised members of staff.
To explain clearly how personal information about your health is recorded and managed in this practice. Your doctor will be happy to discuss this with you.
Your Personal Health Information
Your doctor needs information about your past and present health in order to provide you with high quality care. This practice will make sure that you are able to discuss your health with your doctor in private.
Information is called “personal health information” if it concerns your health, medical history or past or future medical care and if someone reading it would be able to identify you.
Your Medical Records
Your doctor will do his/her best to make sure that your medical records:
- Are accurate, comprehensive, well organised and legible
- Are up to date
- Have enough information to allow another doctor to care for you
- Do not contain offensive or irrelevant comments about you
- Contain a summary of your care, and
- Can be used to remind you, with your permission, to return for follow-up, check ups and reviews.
Your doctor will only collect information which is relevant to your medical care. If you are uncertain as to why information is being requested, ask your doctor.
Providing information to other doctors
The doctors in this practice respect your right to decide how your personal health information is used or disclosed (for example to other doctors). In all but exceptional circumstances, personal information that identifies you will be sent to other people only with your consent.
Gaining your consent is the guiding principle.
It is important that other people involved in your care, such as other doctors, are informed of relevant parts of your medical history so they can best care for you. After discussion with you, your doctor will write a letter to the other doctor, which will be either posted or given to you to take to them. If you have any concerns about this discuss them with your doctor.
In this group practice it is customary for all doctors in the practice to have access to your medical records. If you have any concerns about other doctors being able to see your records, discuss this with your doctor.
Providing your information to others
Your doctor will not disclose your personal health information to a third party unless:
- you have consented to the disclosure, or
- this disclosure is necessary because you are at risk of harm without treatment and you are unable to give consent. For example, you may be unconscious after an accident, or
- your doctor is legally obliged to disclose the information (eg. Notification of certain infectious diseases or suspected child abuse, or a subpoena or court order) or
- the information is necessary to obtain Medicare payments or other health insurance rebates, or
- this disclosure is necessary for the doctors in the practice to carry out a review of their practice for the purpose of improving the quality of care provided and the activity has been approved under Commonwealth or State legislation or by a medical College. This provides safeguards to protect the confidentiality of the information provided, or
- there is an overriding public interest in the release of the information.
In any of the above cases only information which is necessary to achieve the objective will be provided.
Using health information for quality improvement and research
We use patient health information to assist in improving the quality of care we give to all our patients by reviewing the treatments used in the practice.
We may also use information that cannot be identified with you in research projects to improve health care in the community. You will normally be informed if your information is to be used for this purpose and will have the opportunity to refuse to have your unidentifiable information used in this way.
In some circumstances, where the research serves an important public interest, identifiable medical information can be used for medical research without your consent under guidelines issued by the National Health and Medical Research Council.
This research must be approved by an official ethics committee.
Wherever practicable, the information used for research will not be in a form that would enable you to be identified. The publication of research results which use your information will never be in a form that would enable you to be identified.
Security of information in the practice
All our medical records are computerised. We will ensure that any of your personal information that is put on computer will be kept private in the same way as with your paper records. Our electronic records are password protected and therefore will protect your record from unauthorised access.
Your access to your health information
You have access to the information contained in your medical record. You may ask your doctor about any aspect of your health care including information in your record. We believe that sharing information is important for good communication between you and your doctor and for good health care.
Information in your record can be provided to you by way of an accurate and up to date summary of your case, for instance, if you are moving away and are transferring to a new doctor. Do not hesitate to ask your doctor if you want a summary of your care for any reason. If you request a summary or direct access to your full medical record, your doctor will need to take out any information provided by others on a confidential basis. Your doctor will also need to consider the risk of any physical or mental harm to you or any other person, which may result from disclosure of your health information.
Your doctor will be pleased to provide a full explanation of the health summary or medical record provided.
Depending on what is involved, you may be asked to contribute to the cost of providing the information.
Resolving your concerns regarding the privacy of your health information.
If you have any concerns regarding the privacy of your health information or regarding the accuracy of the information held by the practice, you should discuss these with your doctor. Inaccurate information will be corrected or your concerns noted in the records if it is not possible or desirable to alter the original record.
Further information on Privacy Legislation is available from:
Office of the Federal Privacy Commissioner 1300 363 992
Office of the NSW Health Services Commissioner 02 9268 5588
Community and Health Services Complaints Office (ACT) 02 6205 2222
This information compiled by
Royal Australian College of General Practitioners
Committee of Presidents of Medical Colleges
Australian Medical Association