Draft Pro forma

For Development of Your Health Service’s Own Policy

(Insert Health Service Name Here)

Health Information and Medical Records

The ........HS has obligations under the Commonwealth Privacy Act - Privacy Amendment (Private Sector) Act 2000 to maintain the privacy of personal health information. This includes medical records which may be paper and/or electronic files and includes correspondence, faxes and email that contain medical information.

http://www.medical-record.blogspot.com/

All staff are responsible for protecting medical records against unauthorised access where those records are stored or transmitted.

All staff are responsible for the creation of and maintaining accurate, legible and reliable records and protecting them against loss.

All staff are responsible for ensuring pathology test results and any other papers containing personal health information are not left where they may be accessed by unauthorised persons.

All staff are responsible for ensuring the safe and secure storage of medical records.

Medical records are the property of ......HS.

Clients have a right to access their medical records.

Content

• Every client has an individual client health record containing all clinical information relating to him/her.
• Every client health record includes a health summary.
• Client information such as address, contact person in an emergency, health summary is updated regularly so the record remains current and accurate.
• Allergy (known/no known) status is recorded. Alerts are recorded.
• Client information is recorded in a way that allows other staff to read, understand and continue client care.
• Information is entered into the health record at the time of each consultation (including after hours, home visits, telephone calls) or as soon as possible after.

Access

• Access to patient medical records is available to ......HS clinic workers only.
• Paper files are not left exposed on the reception desk, in waiting room or other public areas.
• Medical information is filed and/or scanned as soon as possible.
• Paper records are returned to filing cabinet/compactus/other as soon as possible.
• Computers are positioned to prevent unauthorised viewing of patient information. Screen savers are in use.
• Electronic records are only accessed by clinical staff via secure login/password.
• Electronic records are closed when not in use.
• Clinics are locked after hours.

Procedure – Paper Files

• Use tracer card when removing a medical record from the filing location.
• Return the records to the filing system as soon as possible after use.

Procedure – Electronic/Computer Files

• Record closed after use.
• Regular backups undertaken.

Filing

• All medical records must be filed for easy retrieval, ongoing use and maintenance.
• ·All staff are responsible for filing and for the safe storage of medical records.
• .......HS currently uses the numerical/alphabetical/other ...... system for filing paper medical records.
• .........HS patients have the following file numbers
• Paper file
• Electronic record
• Hospital registration number (HRN)

Medical Information

• Information such as results (pathology, x-ray etc), correspondence or specialist reports are dated and checked prior to being filed within the appropriate medical record as soon as possible. It is important to ensure confidentiality of material waiting to be filed is maintained.
• Medical correspondence is scanned/ kept in patient paper file. Once scanned the original copy is shredded.
• Electronic results are checked and appropriate action marked.

Errors

• Errors in a paper file are corrected by crossing a single line through the entry. This is then initialled, dated with a brief explanation written beside or below.
• Errors in an electronic record are noted, recorded and dated by referring to the wrong information.
• A client may have their personal information amended if they can prove the information is untrue.

Storage

• Clinics are locked after hours.
• Backups are performed ........................
• Backups are kept in a secure place.
• An IT Information Disaster Plan policy is in place.
• Paper records are kept in vermin-proof storage when not in use.

Transfer of information

• Transfer of information to and from another provider is only by patient consent.
• Information includes name and address of client, date of birth, medicare number, name and address of provider.
• Information may only be sent via email if it is securely encrypted.

Faxes must have confidential written on cover sheet. Always check number before being sent.

• Mail requiring to be posted must be left in a secure area out of public view and access.

Removal

Paper/electronic records are not removed from the clinics except in the following circumstances:

i. Attending to a patient outside the clinic if a clinic consultation is not possible.

ii. Outstation visits.

iii. Subpoenaed medical records or other valid written warrant requesting the medical record.

Retention of Records

Recommendation 21 of the “Bringing them home. Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families”, This Recommendation 21 has been adopted by the Federal Government to assist in researching Stolen Generation family links.

“That no records relating to Indigenous individuals, families or communities or to any children, Indigenous or otherwise, removed from their families for any reason, whether held by government or non-government agencies, be destroyed.”

Archiving

• Where clients have not been seen for between 7 to 15 years, client files can be archived and stored off-site in a secured location.
• All clients who are 28 years of age or younger, regardless of the last time they presented for a consultation.
• Records are culled annually.
• Records of deceased patients are marked, “DECEASED” on the record and filed in a separate/inactive section of the storage area.
• Records of Drugs of Addiction stock and administration are retained for a minimum of 3 years.

Disposal

Medical information that has been scanned into a patient file is shredded in the clinic.

RACGP 3^rd Edition 1.7; 4.2

ISO: Australian Standard for Records Management (AS ISO 15489).

Associated P&P: Confidentiality; Client Access to Personal File; 3^rd Party Access to Clinical File; Computer Policy

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