This action states

The health service organisation providing clinical information into the My Health Record system has processes that:

  1. Describe access to the system by the workforce, to comply with legislative requirements
  2. Maintain the accuracy and completeness of the clinical information the organisation uploads into the system

Intent

Clinical information held in the My Health Record system is accurate, complete and accessible by authorised clinicians.

Reflective questions

How does the health service organisation manage the policy implications and risks associated with introducing the My Health Record system?

How does the health service organisation check the accuracy and completeness of clinical information in the My Health Record system?

Key tasks

  • Develop, maintain and regularly review organisational policies for using the My Health Record system, to ensure that access follows the requirements of the My Health Records Act 2012
  • Take reasonable steps to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading, and that any amendments made to these clinical documents are also loaded into the system.

Strategies for improvement

Hospitals

Health service organisations that use, or load documents into, the My Health Record system are required to develop and maintain a My Health Record system policy that outlines the:

  • Process for authorising clinicians to use the system, and for deactivating accounts of those who no longer need access
  • Training to be provided to the workforce on the professional and legal obligations in using the system
  • Physical and technical security measures to control access to the system
  • Identification and management of system-related security risks to be escalated to the executive.

Implementing these strategies would be considered reasonable steps to ensure the accuracy of the records uploaded. Regularly review this policy to ensure that it is up to date and in line with any changes to the My Health Records Act 2012.

The Act also requires that health service organisations take reasonable steps to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading. If a clinical document on the My Health Record system contains incorrect information, the organisation should remove the incorrect version as soon as practically possible.

A clinical document may be subsequently amended or updated. This can occur, for example, when diagnostic test results are provided and the discharge summary is reissued with these results added. In such cases, the corrected version should be loaded into the My Health Record system.

Conduct periodic audits to ensure that:

  • Clinicians loading information into, or amending information in, the My Health Record system do so following the organisation’s policies, procedures and protocols
  • Access to data and records complies with legislative requirements.

Examples of evidence

Select only examples currently in use:

  • Audit results of compliance with policies, procedures or protocols about healthcare records management
  • Audit results of completeness and integration of healthcare records systems.

See the Australian Digital Health Agency website for information on how to register with the My Health Record system.

Day Procedure Services

Health service organisations that use, or load documents into, the My Health Record system are required to develop and maintain a My Health Record system policy that outlines the:

  • Process for authorising clinicians to use the system, and for deactivating accounts of those who no longer require access
  • Training to be provided to the workforce on their professional and legal obligations in using the system
  • Physical and technical security measures to control access to the system
  • Identification and management of system-related security risks to be escalated to the executive.

Regularly review this policy to ensure that it is up to date and in line with any changes to the My Health Records Act 2012.

The My Health Records Act requires that health service organisations take reasonable steps to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading. If a clinical document on the My Health Record system contains incorrect information, the organisation should remove the incorrect version as soon as practically possible.

A clinical document may be subsequently amended or updated. This can occur, for example, when diagnostic test results are provided and the discharge summary is reissued with these results added. In such cases, the corrected version should be loaded into the My Health Record system.

Conduct periodic audits to ensure that:

  • Clinicians loading documents into, or amending information in, the My Health Record system do so following the organisation’s policies, procedures and protocols
  • Access to data and records complies with legislative requirements.

Implementing the strategies above would be considered a reasonable step towards ensuring the accuracy of the records uploaded.

See the Australian Digital Health Agency website for information on how to register with the My Health Record system.

Examples of evidence

Select only examples currently in use:

  • Audit results of compliance with policies, procedures or protocols about healthcare records management
  • Audit results of completeness and integration of healthcare records systems.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group and use My Health Record should use the established system for entering clinical information locally.

Small hospitals that are not part of a local health network or private hospital group and use My Health Record should ensure that:

  • Policies and processes for accessing the My Health Record system are developed, maintained and regularly reviewed to ensure that access is in accordance with requirements under the My Health Records Act 2012
  • Steps are taken to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading, and that any amendments made to these clinical documents are also loaded into the system.

Health service organisations that have access to, or load documents into, the My Health Record system are required to develop and maintain a My Health Record system policy that outlines the:

  • Process for authorising clinicians to use the system, and for deactivating accounts of those who no longer need access
  • Training to be provided to the workforce on their professional and legal obligations in using the system
  • Physical and technical security measures to control access to the system
  • Identification and management of system-related security risks to be escalated to the executive.

Examples of evidence

Select only examples currently in use:

  • Audit results of compliance with policies, procedures or protocols about healthcare records management
  • Audit results of completeness and integration of healthcare records systems.

See the Australian Digital Health Agency website for information on how to register with the My Health Record system.

Hospitals

Health service organisations that use, or load documents into, the My Health Record system are required to develop and maintain a My Health Record system policy that outlines the:

  • Process for authorising clinicians to use the system, and for deactivating accounts of those who no longer need access
  • Training to be provided to the workforce on the professional and legal obligations in using the system
  • Physical and technical security measures to control access to the system
  • Identification and management of system-related security risks to be escalated to the executive.

Implementing these strategies would be considered reasonable steps to ensure the accuracy of the records uploaded. Regularly review this policy to ensure that it is up to date and in line with any changes to the My Health Records Act 2012.

The Act also requires that health service organisations take reasonable steps to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading. If a clinical document on the My Health Record system contains incorrect information, the organisation should remove the incorrect version as soon as practically possible.

A clinical document may be subsequently amended or updated. This can occur, for example, when diagnostic test results are provided and the discharge summary is reissued with these results added. In such cases, the corrected version should be loaded into the My Health Record system.

Conduct periodic audits to ensure that:

  • Clinicians loading information into, or amending information in, the My Health Record system do so following the organisation’s policies, procedures and protocols
  • Access to data and records complies with legislative requirements.

Examples of evidence

Select only examples currently in use:

  • Audit results of compliance with policies, procedures or protocols about healthcare records management
  • Audit results of completeness and integration of healthcare records systems.

See the Australian Digital Health Agency website for information on how to register with the My Health Record system.

Day Procedure Services

Health service organisations that use, or load documents into, the My Health Record system are required to develop and maintain a My Health Record system policy that outlines the:

  • Process for authorising clinicians to use the system, and for deactivating accounts of those who no longer require access
  • Training to be provided to the workforce on their professional and legal obligations in using the system
  • Physical and technical security measures to control access to the system
  • Identification and management of system-related security risks to be escalated to the executive.

Regularly review this policy to ensure that it is up to date and in line with any changes to the My Health Records Act 2012.

The My Health Records Act requires that health service organisations take reasonable steps to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading. If a clinical document on the My Health Record system contains incorrect information, the organisation should remove the incorrect version as soon as practically possible.

A clinical document may be subsequently amended or updated. This can occur, for example, when diagnostic test results are provided and the discharge summary is reissued with these results added. In such cases, the corrected version should be loaded into the My Health Record system.

Conduct periodic audits to ensure that:

  • Clinicians loading documents into, or amending information in, the My Health Record system do so following the organisation’s policies, procedures and protocols
  • Access to data and records complies with legislative requirements.

Implementing the strategies above would be considered a reasonable step towards ensuring the accuracy of the records uploaded.

See the Australian Digital Health Agency website for information on how to register with the My Health Record system.

Examples of evidence

Select only examples currently in use:

  • Audit results of compliance with policies, procedures or protocols about healthcare records management
  • Audit results of completeness and integration of healthcare records systems.

MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group and use My Health Record should use the established system for entering clinical information locally.

Small hospitals that are not part of a local health network or private hospital group and use My Health Record should ensure that:

  • Policies and processes for accessing the My Health Record system are developed, maintained and regularly reviewed to ensure that access is in accordance with requirements under the My Health Records Act 2012
  • Steps are taken to ensure that clinical documents provided to the My Health Record system are accurate at the time of loading, and that any amendments made to these clinical documents are also loaded into the system.

Health service organisations that have access to, or load documents into, the My Health Record system are required to develop and maintain a My Health Record system policy that outlines the:

  • Process for authorising clinicians to use the system, and for deactivating accounts of those who no longer need access
  • Training to be provided to the workforce on their professional and legal obligations in using the system
  • Physical and technical security measures to control access to the system
  • Identification and management of system-related security risks to be escalated to the executive.

Examples of evidence

Select only examples currently in use:

  • Audit results of compliance with policies, procedures or protocols about healthcare records management
  • Audit results of completeness and integration of healthcare records systems.

See the Australian Digital Health Agency website for information on how to register with the My Health Record system.