Managing health information

The RACGP has produced a booklet called, “Handbook for the Management of Health Information in Private Medical Practice”. No practice should be without a copy particularly if this is an accreditation or reaccredidation year. Call the division or contact your practice liaison officer for a copy.

Your practice should talk through confidentiality issues and have policies and procedures for all situations, as decisions on the run by whoever is there at the time are not always the best option.

Here are a few questions that you need to ask at your next practice meeting.
Do you think calling a patient by their full name from the waiting room before being seen by the doctor is breaching their confidentially? If the patient asks that in future they would like to be called only by their first name, have you a system in place for this to happen?

Does your staff sign a confidentiality form before starting employment, explaining your policies and consequences of not complying? Do you have a similar confidentially form for visiting or part time workers or contractors?

Have you a standard consent form? Is notation of patient verbal consent kept routinely in their records? Do you know when the practice needs written or oral consent rather than implied?

What is the procedure in your practice when a patient requests to see their notes and does it comply with the guidelines? Is the patient informed that they will be put on a database and may be sent a reminder? What does the practice do if a patient refuses to be part of a database in a computerised practice?

Can you take a family medical history without the permission of the family? When can you legally breach patient confidentiality?

All these will be dealt with on this page in the coming issues and are also dealt with in the book. Please email any extra questions that you would like this section to address. While the question may be published, the author’s details will be withheld.

Can you call out a patient’s full name when it is their turn to see the doctor?
Revealing a patient’s full name to the rest of the waiting room is identifying the patient to all who can hear. There is no clear detailing about this situation in the handbook. I bring this situation to your attention, particularly as it was a complaint made by a member of the Lismore public about her doctor’s surgery.

If your surgery has always referred to patients in the waiting room by their full name and the patient expects this every time s/he comes and the patient doesn’t complain about this system, then the consent to continue in this matter is implied. Perhaps an option could be given to them in the form of a sign or note in the practice information sheet. This is just my suggestion and I would like to hear from others. What does your practice do?

What about new patients? Should they be asked how they would like to be addressed in the waiting room as they don’t know the system used in your practice? Is there a facility within your practice’s records to make allowances for patient preferences of salutation and is it used correctly?