Medical records
Medical records contain personal health information which is used by doctors at Leeton Medical Practice to manage and plan patient health care.
A typical medical record will contain information such as:
- patient identification sheet
- •notes recording patient care
- summaries and reports from consulted specialists and diagnostic services
- test results
- prescribed medications
It is necessary to collect and keep this information to provide a history of patient health care and to identify safe and effective future treatments.
Some of the information collected by the clinic may also be used to evaluate our service and plan for the future. If a medical record is used for this purpose, information that identifies the patient will be removed.
Patient confidentiality
Leeton Medical Practice respects the rights of patients to decide how their personal health information is used or disclosed.
Leeton Medical Practice will always ensure that patients:
- agree to have their personal health information collected
- consent to any disclosure to a third party
Reasons personal health information may be disclosed to a third party include:
- seeking a second opinion from another medical practitioner
- referral to a specialist
- requesting diagnostic testing or examination (such as pathology or radiology)
- admission to casualty or hospital
- disclosure to obtain Medicare or insurance payments
- medical research
Disclosure of personal health information without patient consent will only occur in situations where:
- the doctor is compelled by court order
- the doctor believes that a higher duty prevails in order to protect the public interest
- the disclosure is necessary to avoid a serious risk of harm to the person concerned
- there is a legal obligation under applicable Commonwealth or State legislation eg statutory provisions requiring the notification of certain infectious diseases or suspected child abuse.
Patient access to medical records
Under the Privacy Act 1988, patients have the right to request amendments be made if the record contains information that is:
- inaccurate
- incorrect
- out of date
- misleading
If a patient requests an amendment, the doctor concerned should add notes to the record to indicate the nature of the request and the changes made.
If a patient requests access to their medical record, this information can be provided by way of a summary. Provision of a medical record or summary should always be accompanied by an explanation from the doctor and an offer to discuss any patient concerns.
On rare occasions, a doctor may request that some information not be made available to a patient. This may be necessary if it is believed the information may be detrimental to a patient’s health and wellbeing if read by the patient.
If requested by a patient, the clinic will also transfer a copy of the medical record or summary to another medical clinic or practitioner.
Storage and security
Active records
Medical records (computerized and paper) are retrievable only by authorized staff at Leeton Medical Practice
Leeton Medical Practice is legally obliged to keep medical records for 7 years. The medical records of a
minor must be held until the patient turns 25.
All active records are stored securely on the premises.
Inactive records
A medical record is considered inactive when a patient has not attended the clinic for more than three years.
Doctors will be responsible for confirming that a patient’s medical record is inactive. The doctor will then produce a summary of the medical record and advise administration staff of the need for archiving.
Reception staff will arrange archiving of inactive medical records and archived records will be reviewed annually and destroyed as required.