This leaflet aims to explain clearly how personal information about you and your health is recorded and managed within Stockton Surgery. Your doctor will be happy to discuss this with you:
A Patient Health Record
A patient health record contains medical information such as medical history, care or treatment received, test result, diagnoses and medications.
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.
This practice follows the guidelines of the "Handbook for the Management of Health Information in Private Medical Practice". The Handbook was produced by the Royal Australian College of General Practitioners and the Committee of Presidents of Medical Colleges with the support of the General Practice Computing Group. The Handbook incorporates the provisions of Federal and State Privacy Legislation. This means that your personal health information is kept private and secure.
The practice has a written policy on personal health information – this policy is available to all patients for inspection
What personal information do we collect?
The information we will collect about you includes your:
• names, date of birth, address, contact details
• medical information including medical history, medications, allergies, adverse events, immunisations, social history, family history and risk factors
• Medicare number (where available) for identification and claiming purposes
• healthcare identifiers
• medical information including medical history, medications, allergies, adverse events, immunisations, social and family history and risk factors.
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.
Providing your information to other doctors
The doctor(s) at Stockton Surgery 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. At Stockton Surgery, it is customary for all doctors to have access to all the medical records. If you have any concerns about other doctors at this practice being able to see your records discuss your concerns with your doctor.
It is important that other people involved in your care, such as other doctors or health professionals, are informed of relevant parts of your medical history so they can best care for you. Your doctor will let you know before this occurs. If you have any concerns about this discuss them with your doctor.
All employees of Stockton Surgery are bound by confidentiality agreements.
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 might be unconscious after an accident; or your doctor is legally obliged to disclose the information (e.g., 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
there is an overriding public health and safety interest in the release of the information.
There are times when 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.
This provides safeguards to protect the confidentiality of the information provided. In any of the above cases only information which is necessary to achieve the objective will be provided.
This practice also participates in national/state or territory reminder systems/registers.
If you do not wish to participate please inform the Doctor or receptionist.
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 does not identify 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 unidentified information used in this way. 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 enables you to be identified.
In some circumstances, where the research serves an important public interest, identifiable medical records 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.
Security of information in the practice
All your medical records at Stockton Surgery are kept in electronic form. We will ensure that any of your personal information that is put on computer will be kept private in the same way as occurs with paper records. This will protect your record from unauthorised access.
We support Electronic Health Records. Australia has an opt out system as of June 2019. Patients who have not opted out will have an automatically generated health record with basic medication details and dates of visits to Health Professionals. With patient permission we can upload a Health Summary as well. Not every visit every time is uploaded. Doctor will upload a new summary if there is a new diagnosis or changes in medication. If you do not wish to have information uploaded, you can let your doctor know this.
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 in a number of ways if for example, 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 consider the risk of any physical or mental harm to you or any other person which may result from disclosure of your health information, and may need to remove any information that may impact on the privacy of other individuals.
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. For legal reasons, the original notes cannot be altered and must be retained.
Further information on Privacy Legislation is available from:
Privacy and managing health information in general practice – is available to view online.
How can you lodge a privacy related complaint, and how will the complaint be handled at our practice?
We take complaints and concerns regarding privacy seriously. You should express any privacy concerns you may have in writing. We will then attempt to resolve it in accordance with our resolution procedure. All complaints will be addressed within 30 days of receiving the complaint.
Complaints can be emailed to firstname.lastname@example.org
or mailed to
Stockton Surgery – 78 Mitchell Street, Stockton NSW 2295
You may also contact the OAIC. Generally, the OAIC will require you to give them time to respond before they will investigate. More information is at www.oaic.gov.au or call the OAIC on 1300 363 992.
Policy review statement
This policy will be reviewed to ensure it is in accordance with any changes that may occur.
Next review date: November 2020.
The current policy is displayed on website and an updated copy can be accessed at the practice.
Further information on Privacy Legislation is available from:
Office of the Federal Privacy Commissioner 1300 363 992
Office of the Health Services Commissioner (Victoria) 1800 136 066
Community and Health Services Complaints Office (ACT) 02 6205 2222
78 MITCHELL STREET
STOCKTON NSW 2295