Healthcare records

Healthcare records provide one of the most important information sources available to healthcare providers. Undocumented or poorly documented information relies on an individual healthcare provider’s memory and is less likely to be communicated and retained. This can lead to a loss of information, which can result in misdiagnosis, and inadequate or inappropriate treatment and harm. 

Healthcare records can be paper-based, electronic or a mix of both. Irrespective of the form, an effective healthcare record system must be applied consistently. This includes:

• When creating, maintaining and using patient healthcare records
• Recording patient notes and relevant communications between healthcare providers
• Complying with relevant privacy and security regulations. 

The records should be designed so they can be audited for clinical review and improvement. Healthcare services should have a process for patients to access their healthcare records.

For detailed information about what should be included in a patient’s healthcare record, refer to the Explanatory notes in Action 3.26.

Links to Actions 1.12, 1.13 and 1.14 Healthcare records and 3.26 Processes for effective communication

• How do healthcare providers access healthcare records at the point of patient care?
• How are healthcare providers supported to record patient notes, file relevant communications with other healthcare providers and ensure healthcare records are complete, current and up to date? 
• How are healthcare records stored securely?
• What processes are in place for auditing healthcare records?
• How can patients access their healthcare records?

• Implement a process to create, maintain and use healthcare records that
  • makes healthcare records available to healthcare providers at the point of care
  • supports healthcare providers to maintain accurate and complete healthcare records 
  • complies with privacy and security regulations.
• Conduct regular audits of healthcare records to identify areas for safety and quality improvement. 
• Implement a process to facilitate a patient’s access to their healthcare record when required or requested.
• Provide training to healthcare providers about the healthcare record system during orientation and refresher training as required.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Policy documents on healthcare record management, including access, storage, security, consent and sharing patient information
• Audit templates or reports on results of healthcare records for compliance with policies or procedures
• Demonstration or observation of how healthcare records are accessible at the point of patient care
• Training (for example, syllabus, attendance records, competency assessments) relating to the healthcare records system
• Documented information system management, data security and data breach protocols
• Observation of safe and secure storage systems for healthcare records, including evidence of fire protection and pest control strategies.

Resources

• Office of the Australian Information Commissioner: Privacy in your state – looks at what privacy laws apply in each state and territory and for private sector health service providers.
• Office of the Australian Information Commissioner: Privacy for health service providers – provides additional information about healthcare provider obligations.
• Open Notes website: information about an international movement advocating for improving how medical information is shared with patients and their care partners. 
• The Privacy Act 1988 (the Privacy Act) – outlines the privacy responsibilities that most healthcare providers have to comply with in managing health and personal information. The key requirements are contained in the Australian Privacy Principles (APPs).

Reports from other healthcare providers, such as patient referrals, medication reviews, pathology or diagnostic imaging results can be a critical component in determining the course of action in a patient’s health care. 

Ensuring a healthcare service has established processes to receive, review, act on and document reports on patients will minimise the risk of loss of information, which can result in misdiagnosis and harm. This should include processes for receiving and actioning urgent reports when a patient’s healthcare provider is unavailable, or reports are received out of hours.

Links to Actions 1.11, 1.13 and 1.14 Healthcare records and 3.26 Processes for effective communication

• How are patient reports received, reviewed, actioned and documented in your healthcare service?
• What processes are in place to recall patients when needed to discuss patient reports, identified risks and subsequent health care options? 

• Implement a process to consistently
  • receive reports on patients and have reports reviewed by relevant healthcare providers and take action on reports in a timely manner
  • recall patients when required to discuss reports and subsequent health care options and risks
  • document reports in a patient’s healthcare record. 
• During orientation and/or when needed, explain to healthcare providers about processes to receive, action and record patients’ reports.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Policies, procedures and protocols that describe
  • how patient reports are received, reviewed, actioned and documented in a timely manner
  • how patient recalls are managed
  • processes to communicate about patient reports and health care options
• Example of patient reports that have been received, reviewed, actioned and documented in a patient’s healthcare record.

Resources relating to this Action may be added as they become available.

Note: This action is only applicable if your healthcare service uses My Health Record.

My Health Record is a secure online summary of a patient’s key health information and is available to all Australians.^[i] Healthcare providers registered with My Health Record can upload and view patient information. This may include information uploaded by your patient’s other healthcare providers, and this information can be used for planning and delivery of health care. Information available through My Health Record can include a patient’s health summary, medication prescribing and dispensing history, pathology reports, diagnostic imaging reports and discharge summaries.8

Healthcare identifiers are unique numbers. They are used in health-related information to clearly identify the patient, the treating professional and the organisation where healthcare is provided. They reduce the potential for errors with healthcare related information and communication. In Australia, the Healthcare Identifiers (HI) Service is a national system for uniquely identifying, healthcare providers, healthcare organisations and individuals receiving healthcare. These include: 

• Individual Healthcare Identifier (IHI) – identifies a patient (individual) receiving healthcare. An IHI uniquely identifies individuals who receive healthcare, including Australian citizens, permanent residents and visitors to Australia 
• Healthcare Provider Identifier – Individual (HPI-I) – identifies an individual healthcare provider who provides healthcare, such as general practitioners and rural generalists, allied health professionals, specialists, nurses, dentists and pharmacists, among others 
• Healthcare Provider Identifier – Organisation (HPI-O) – identifies the healthcare provider organisation where healthcare is provided, such as hospitals, medical practices, pathology or radiology laboratories and pharmacies. Healthcare providers must be registered with the HI Service and assigned healthcare identifiers to access a patient’s My Health Record.

Standard national terminologies are structured vocabularies used in clinical practice to accurately describe the care and treatment of patients. Healthcare providers around the world use specialised vocabulary to describe diseases, operations, clinical procedures, findings, treatments and medicines. In Australia, terminologies include SNOMED CT-AU and Australian Medicines Terminology (AMT). 

Healthcare services that use My Health Record system must have processes to: 

• Use national healthcare identifiers for patients and healthcare providers 
• Use standard national terminologies when uploading patient reports and information 
• Support healthcare providers to use My Health Record to optimise safe, high-quality health care. 

Links to Actions 1.11, 1.12 and 1.14 Healthcare records and 3.26 Processes for effective communication

• How does using My Health Record in your healthcare service benefit patients? 
• How is your service using national healthcare identifiers and standard national terminologies? 
• How is the workforce supported to use My Health Record?

• Develop and implement a process for the use of My Health Record that includes using unique national identifiers for patients, healthcare providers and healthcare service organisations in local information systems and in clinical documents loaded into the My Health Record system.
• Implement standard national terminologies such as AMT in healthcare records and clinical documents loaded to My Health Record.
• Support the workforce to use standard national terminologies when uploading to My Health Record by facilitating access, providing training and making resources available.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 

• Evidence of registration with and contributions to My Health Record 
• Documented processes for accessing and contributing to My Health Record using national healthcare identifiers and standard national terminologies 
• Example of an entry by the healthcare service in My Health Record
• Training records relating to My Health Record (for example, syllabus, attendance records, competency assessments).

Resources

• Australian Digital Health Agency: My Health Record – provides a suite of training, resources and guides. 
• National Clinical Terminologies Service: What is clinical terminology? –  the service is operated by the Australian Digital Health Agency, and is responsible for managing, developing and distributing national clinical terminologies and related tools and services. 
• Office of the Australian Information Commissioner: Healthcare identifiers – the OAIC is the independent regulator of the privacy aspects of the Healthcare Identifiers Act 2010 (HI Act) and the Healthcare Identifiers Regulations 2010 (HI Regulations).

Note: This action is only applicable if your healthcare service uses My Health Record.

My Health Record is a secure online summary of a patient’s key health information and is available to all Australians.⁸ Healthcare providers registered with My Health Record can upload and view patient information, including information uploaded by other healthcare providers. This information can be used in the planning and delivery of health care. Information available through My Health Record can include a patient’s health summary, medication prescribing and dispensing history, pathology reports, diagnostic imaging reports and discharge summaries.⁸

Healthcare services providing clinical information to My Health Record are required to comply with a range of legislative requirements, including:

• My Health Records Act 2012
• My Health Records Rule 
• My Health Records (Assisted Registration) Regulation.^[i]

More detailed information about these obligations is available on the My Health Record website. 

As part of these obligations, your healthcare service must ensure clinical information uploaded is accurate and complete. Undocumented or poorly documented records can lead to a loss of information, which can result in misdiagnosis and harm. 

Links to Actions 1.11, 1.12 and 1.14 Healthcare records and 3.26 Processes for effective communication

• How is information uploaded to My Health Record in your healthcare service?
• How is clinical information reviewed for accuracy and completeness before uploading to My Health Record?

• Implement a process that can be used to upload relevant clinical information to My Health Record using compliant clinical software, ensuring information uploaded is accurate and complete. 
• Provide training to healthcare providers on how to upload information to My Health Record.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Process for uploading clinical information to My Health Record, including steps to ensure accuracy and completeness of information uploaded 
• Training documents (for example, syllabus, attendance records and competency assessments) on how to access and contribute to patient information in the My Health Record system 
• Examples of clinical information uploaded by the healthcare service in My Health Record.

Resources

• Australian Digital Health Agency: My Health Record website – provides a suite of information and resources regarding viewing and uploading clinical information.