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Transfer of health information between healthcare professionals

1 Sep 2016

Summary

The MCNZ Good Practice guidelines provide that patients should know how information is shared among those who provide their care. Additionally, under the Health and Disability Code of Rights, right 3 clause 5 states 'Every consumer has the right to co-operation among providers to ensure quality and continuity of services' which includes timely transfer of health information.1

Practitioners should seek the patient’s permission to, and explain the benefits of, sharing relevant information with other health practitioners and agencies involved in their care, including their principal health provider.

Once the patient’s permission to share information has been obtained, practitioners must promptly provide their colleagues with the information they need to ensure that the patient receives appropriate care without delay.2

In most situations, health information should not be passed on without consent, however, some situations exist in which colleagues should be informed even without patient consent. For example, the Health Act 1956 provides that medical records or health information of any kind may be provided at the request of another practitioner providing ongoing care for the patient.3

Transfer of records should be made promptly on request, and the existence of outstanding accounts is no excuse for refusal or delay. Video recordings, x-rays and CAT scans are exceptions to this rule.4

Under Rule 6 of the Health Information Privacy Code: ‘Requests do not necessarily have to be dealt with immediately, but agencies must have procedures that allow requests to be dealt with as soon as reasonably practicable and within 20 working days.'5

The record to be transferred would usually be the electronic file, the paper (hard copy) file, or a print out of the electronic file. At the minimum it should consist of a brief factual summary of what records the doctor has along with a note of the present state of the patient’s health.

Practitioners transferring notes electronically, for example between general practitioners using GP2GP must ensure that any paper (hard copy) files are also transferred.

It is strongly recommended that the agency retain a copy or summary of the records whenever a patient’s medical records are transferred to another doctor, especially if there has been any suggestion of a complaint.

Partnerships of doctors operate as single agencies under the Health Information Privacy Code (HIPC), and their obligations under the Code may apply to all the health information held under the partnership. This would likely include locums working for a practice/partnership. A doctor leaving a practice or a partnership has no automatic right to take patient records with them.

Increasingly systems are available for practitioners to access information contained in the electronic record of another provider. Where practicable, doctors must obtain consent from the patient or a representative of the patient before accessing this information, and record that they have obtained this consent. Audits are performed on access to these systems, and unauthorised access will not be tolerated.

Patient portals provide another avenue for different providers to view information contained in the primary health record. This access must be done by the patient themselves, and may provide more information (such as the daily record notes) than would be available through other systems.

References

  1. www.hdc.org.nz/the-act--code/the-code-of-rights/
    the-code-(summary)
  2. MCNZ, Statement on Good Medical Practice (December 2016)
  3. Health Act s 22F, 1956
  4. MCNZ Statement, The Maintenance and Retention of Patient Records (August 2008).
  5. www.privacy.org.nz/assets/Files/Codes-of-Practicematerials/
    HIPC-1994-2008-revised-edition.pdf

    page 42