The application of this Part extends to a former patient, and to the records relating to a former patient, in the same way as it applies to a patient and to the records relating to a patient.
2. Health records
(1) A record is to be kept of the medical condition of each patient in a private hospital or day-procedure centre and a record of all medical, nursing and other care provided to the patient must be maintained by an entry in a patient health record system made by the appropriate medical, nursing or other health care provider.
(2) Without limiting subclause (1) , the health record of a patient is to include the following:
(a) the patient’s admission form;
(b) the patient’s medical history and results of any physical examination, which may be contained in any referral document;
(c) any medical consultation reports;
(d) a record of any medication administered;
(e) a record of allergies and other factors requiring special consideration;
(f) reports of all laboratory tests performed;
(g) reports of all X-ray and other medical imaging examinations performed;
(h) the name of any person whose consent to the carrying out of medical or dental treatment is necessary;
(i) consent or request forms, if applicable;
(j) if a medical, surgical or other procedure has been performed;
(k) in a case where anaesthesia has been employed, the anaesthetic record (which must comply with the recommendations of PS06 Guideline on the anaesthesia record as published by the ANZCA);
(l) the procedure report, including the pre-procedural and post-procedural diagnoses, and a description of the findings, technique used and tissue removed or altered;
Part Part 5 - Health Service Establishments Regulations 2021 - Health records | Zoe
(m) in a case where tissue or body fluid has been removed, any pathological report on the tissue or body fluid;
(n) in a case where the procedure has involved surgery, a record of the swab, sponge and instrument count;
(o) the post-procedural recovery record;
(p) a discharge statement, completed by the medical practitioner or dentist attending the patient, that specifies any major procedures performed, the final diagnosis, the patient’s condition and recommendations and arrangements for the patient’s future care.
(3) Any records relating to medical or dental treatment are to identify the medical practitioner or dentist by whom that treatment was provided.
(4) A discharge statement referred to in subclause (2)(p) must be completed before the patient’s discharge unless discharge instructions are given orally, in which case the statement must be completed within 48 hours after the patient’s discharge.
3. Retention of records
(1) The register of patients, together with the patients’ health records, must be retained as follows:
(a) the register of patients must be kept indefinitely;
(b) health records relating to patients (other than maternity patients) of 18 or more years of age at the date of last separation must be kept for 7 years from the date of last separation;
(c) health records relating to patients (other than maternity patients) of less than 18 years of age at the date of last separation must be kept until the patient to whom the record relates attains, or would have attained, the age of 25 years.
(2) The documents referred to in subclause (1) must be given to the transferee if the licence for the private hospital or day-procedure centre is transferred to another person.
(3) If the licence for the private hospital or day-procedure centre is surrendered or cancelled, the licensee must deal with the register and records in accordance with the instructions of the Secretary.
(4) Unless an exemption is granted by the Secretary, the register and records are to be kept at the private hospital or day-procedure centre.
4. Patient’s right of access to health records
(1) A patient or the patient’s representative may, by written application to the licensee, request access to the patient’s health record.
(2) The licensee must, as soon as practicable after the receipt of such an application, make the health record available to –
(a) the patient or the patient’s representative; or
(b) a person nominated by the patient or the patient’s representative.
(3) The licensee may refuse a request by a patient or by the patient’s representative for access to the patient’s health record –
(a) if the medical practitioner or dentist in charge of the patient’s care advises that the request should be refused; and
(b) if the licensee is satisfied that access by the patient or representative would be prejudicial to the patient’s physical or mental health.
(4) An application under this clause is to be retained in the patient’s health record.
5. Manner of providing access
(1) Access to a health record may be given by making the record available for inspection or by providing a copy of the record, as specified by the applicant.
(2) If a person to whom access to a health record is given so requests, the person must be given assistance in the interpretation of the record (including any test results, findings and comments contained in the record) by a person qualified to do so.
(3) If a patient or the patient’s representative requests particular clinical information (such as test results or details of past treatment) rather than access to the patient’s health record, the information may be provided by the medical practitioner or dentist in charge of the patient’s care or, subject to the advice of that medical practitioner or dentist, by a medical practitioner or registered nurse on the staff of the private hospital or day-procedure centre.
(4) If a patient or the patient’s representative disagrees with information contained in the patient’s health record, the licensee must, on request by the patient or patient’s rrepresentative, attach the patient’s or patient’s representative’s own comments in the form of an addendum to the record.
6. Procedure on refusal of request for access
(1) If the licensee refuses a request by a patient or by the patient’s representative for access to the patient’s health record, the licensee –
(a) must inform the patient or representative in writing of the reason for the refusal and of any rights of appeal that may exist in respect of the refusal; and
(b) must include in the patient’s health record a written note of the refusal and the reason given for the refusal.
(2) A patient or the patient’s representative may appeal in writing to the Secretary against a decision of the licensee to refuse access to the patient’s health record.
(3) The Secretary may, in determining such an appeal –
(a) confirm the decision of the licensee; or
(b) direct that the licensee grant the patient or the patient’s representative access to the patient’s health record under such conditions as the Secretary may direct.
(4) A determination made by the Secretary is to be given in writing to the licensee and retained in the health record of the patient to whom it relates.
7. Confidentiality of records
(1) The licensee must ensure that, except as provided by this clause, personal information concerning a patient is not released from the private hospital or day-procedure centre except with the consent of the patient or the patient’s representative or with other lawful excuse.
(2) Subclause (1) does not affect the operation of any other law requiring, prohibiting or restricting the release of any such information.
(3) All health records must be stored in a secure place to which unauthorised persons are not permitted access.