Clinical Documents

Clinical documents support the continuity of care, and improve the interactions between healthcare providers and patients. Our work supports clinical workflow by allowing important patient information to be shared between healthcare providers electronically.

What is a Shared Health Summary?

The structure of a patient's Shared Health Summary is underpinned by the Royal Australian College of General Practitioners (RACGP's), template for a GP health summary, and represents the patient's status as a point in time. The Shared Health Summary may include information about a patient's medical history, including medications they are currently taking, allergies and adverse reactions they may have, or immunisations they have received.

The most recently uploaded Shared Health Summary in a consumer's My Health Record is likely to be the first document accessed by any other healthcare professional viewing a patient's My Health Record.

View Example of a Shared Health Summary

Who can create a Shared Health Summary?

The Shared Health Summary is prepared and uploaded by a patient's nominated healthcare provider who can be a medical practitioner, registered nurse or Aboriginal and Torres Strait Islander health practitioner, and this person should deliver continuing, coordinated and comprehensive care to the individual.

A patient can have only one nominated healthcare provider at a time. If a patient wishes to appoint a new nominated healthcare provider, they can ask another registered healthcare provider to author and upload their Shared Health Summary to the My Health Record system. By doing this upload, that healthcare provider automatically becomes the patient's nominated healthcare provider. (Note: A provider who is not their usual provider could use an Event Summary instead).

When to create or update a Shared Health Summary?

The uploading of a Shared Health Summary is particularly relevant for patients with chronic conditions and co-morbidities. As part of its recommendations for putting the My Health Record system into practice, the RACGP recommends that at the time of completing a patient health assessment (as for example, a GP Management Plan, 75+ Health Assessment, or 4 year old health check) it would be appropriate and timely to post a Shared Health Summary to a patient's My Health Record. This is a time when the health summary within the local GP clinical system is being updated and it would then be an appropriate time to upload to their My Health Record.

To create a Shared Health Summary, the healthcare provider will need to obtain the patient's agreement that:

  • The healthcare provider is to be the individual's Nominated Healthcare Provider;
  • The healthcare provider is to create the Shared Health Summary for the patient.

It is a good idea for the healthcare provider to have a conversation with the patient about the type of information the provider will include in the Shared Health Summary. However, there is no requirement for the patient to review the Shared Health Summary before it is uploaded to their My Health Record. When they register for a My Health Record, the patient provides standing consent for their health information to be uploaded to the My Health Record system. Provided that the patient has agreed for the healthcare provider to create their Shared Health Summary, further consent is not essential given that standing consent has already been provided.

GPs will be able to bill the Medicare Benefits Schedule (MBS) for preparing Shared Health Summaries as part of a consultation. In deciding which item to bill, GPs will only have to consider the reasonable time it would take - not the complexity of the consultation. See MBS Online for information on item numbers relevant to actions related to a patient's My Health Record.

If a nominated healthcare provider wishes to change the information in their patient's Shared Health Summary, e.g. the medications listed, they will need to upload a new Shared Health Summary with the updated information. Note that there is no additional responsibility for a nominated healthcare provider to update a Shared Health Summary outside of a consultation with the patient.

Sections 4.5.3 and 5.4 of the AMA's Guidance to Using the My Health Record system provide guidance to medical practices in these and related areas.

How to create a Shared Health Summary

Click here for demonstrations showing how easy it is to create a Share Health Summary using your clinical software.

What is an Event Summary?

An Event Summary is used to capture key health information about significant healthcare events that are relevant to the ongoing care of an individual. They may contain allergies and adverse reactions, medicines, diagnoses, interventions, immunisations and diagnostic investigations. An Event Summary can be uploaded to a consumer's My Health Record by a healthcare provider at any participating healthcare organisation – such as an after-hours GP clinic, hospital or community pharmacy.

View Example of an Event Summary

Who can create an Event Summary?

An Event Summary can be uploaded by a healthcare provider (with a healthcare provider identifier for individuals; ie an HPI-I) at any participating healthcare organisation. It is important that the information contained in an Event Summary is in a format that can be understood by healthcare providers outside of your own organisation. It should summarise, in narrative form, the presentation of the event, the assessment made, and the action taken. All clinically relevant information should also be recorded and saved in the patient's notes, as per standard practice.

When to create or update an Event Summary?

Event Summaries are intended for healthcare providers to record information relevant in the context of the national My Health Record system, where there is no existing form of communication exchange, such as a Shared Health Summary, Discharge Summary or Specialist Letter. Event Summaries should be uploaded when the provider, based on their professional judgement, believes the information contained within it will be of value to other healthcare providers for the continuity of patient care. They may detail a consultation about a clinical intervention or a Home Medicines Review, for example.

The frequently cited use of an Event Summary is in conjunction with the assessment and treatment of itinerant patients. In this scenario, a patient visits a general practice or health clinic where a healthcare provider is not (and is unlikely to become) the patient's usual provider. Where the encounter is significant and the information is relevant to the patient's ongoing care, the healthcare provider would consider uploading an Event Summary.

When the patient next visits their nominated provider, that nominated provider would review the event summary(s) along with other recent clinical documents, update their local clinical record to reflect changes to the patient's medication regime, medical history, etc., then update and upload the Shared Health Summary to their My Health Record.

In situations where an Event Summary is created, it should be one of the final tasks at the end of the consultation, after the healthcare provider has entered a progress note, updated medical history and made any changes to the patient's medication regime in the local record.

GPs will be able to bill the Medicare Benefits Schedule (MBS) for preparing Event Summaries as part of a consultation. In deciding which item to bill, GPs will only have to consider the reasonable time it would take - not the complexity of the consultation. See MBS Online for information on item numbers relevant to actions related to a patient's My Health Record.

What is a Discharge Summary?

The Agency's Discharge Summary specification supports a national standard for electronically capturing details of a patient's hospital stay in a structured format. The information contained in the Discharge Summary can be shared between the patient's doctor, the referring specialist and a community pharmacy to support the continued care of the patient once they are discharged from hospital.

When a healthcare provider creates a Discharge Summary, it will be sent directly to the intended recipient, as per current practices. When a Hospital is connected to the My Health Record system, a copy of the Discharge Summary can also be sent to the patient's My Health Record.

View Example of a Discharge Summary

Which hospitals are uploading Discharge Summaries?

Over 500 public hospitals are already uploading discharge summaries to the My Health Record system, and more are connecting every month. Click here for the list of hospitals already connected.

What are Medication Records in the My Health Record system?

Healthcare professionals who use clinical software to prescribe and dispense medications can also upload a copy of this information directly to a patient's My Health Record. These medication records can be viewed in the My Health Record system as clinical documents, and are also displayed in the Prescription and Dispense View, which allows individuals and their healthcare providers to easily view details of their prescribed and dispensed medications.

The view displays the name and date a medication has been prescribed and dispensed (both the brand name as well as the active ingredient/s), the strength of the medication (e.g. 2mg, 20mg, etc.), the direction for consumption (e.g. take one capsule daily) and the form of the medication prescribed (e.g. capsule, tablet, inhaler, etc.).

View Example of a Prescription Record

View Example of a Dispense Record

View Example of the Prescription and Dispense View

How to upload Medication Records

If a patient has a My Health Record, their healthcare provider is using Electronic Transfer of Prescriptions (ETP) and is registered with the My Health Record system, a copy of the prescription information will flow through to the My Health Record system via the Prescription Exchange Service (PES) and be visible in the Prescription and Dispense View (as long as the patient has not withdrawn their consent for the information to be uploaded).

Read more about how prescribe and dispense information gets into the My Health Record system under eMedications Management.

  • Click here for software demonstrations showing the uploading and viewing of prescriptions to the My Health Record system.

What is an eReferral?

Referrals are an important clinical process. In Australia, there are many forms of referral-related communications with the majority originating from GPs to Specialists.

The Agency's eReferral specification supports the seamless exchange of significant patient information from one treating healthcare provider to another via a national system of creating, storing and sharing referral reports.

The My Health Record system supports the collection of eReferrals. When a healthcare provider creates an eReferral, it will be sent directly to the intended recipient, as per current practices. A copy may also be sent to the My Health Record system.

eReferrals can be sent and received directly between healthcare providers (point-to-point), through secure messaging, and/or uploaded to and retrieved from a patient's My Health Record (point-to-share).

What information is included in an eReferral?

When an eReferral is created, structured fields give the sender the ability to include information about the patient's:

  • current and past medical history;
  • current medications;
  • allergies / adverse reactions; and
  • diagnostic investigations (optional).

The "Reason for Referral" section provides a free text field for the referrer to include additional content regarding the patient's clinical story. As done with paper referrals, this could include a synopsis of the case, presenting problems, the service that is requested, pertinent history or key physical findings etc.

When coordinating the care of their patients, general practitioners (GPs) may have to refer to specialists for further diagnosis or treatment.

What is a Specialist Letter?

A Specialist Letter is the document used by a treating specialist to respond to a GP about a referred patient. It is based on the usual practice where a specialist writes back to the GP. The Agency's Specialist Letter clinical document takes the paper form and creates an electronic version, allowing for it to be used in communication directly to a GP, and uploaded to an individual's My Health Record. The standard structure creates an efficient way of displaying key information about the visit, such as diagnoses and medications.

What information is included in the Specialist Letter?

When a Specialist Letter is created, structured fields give the sender the ability to include information about the patient's:

  • recommendations;
  • medications and medication review;
  • adverse reactions; and
  • diagnostic investigations (optional).

The "Response Narrative" section provides a free text field for the specialist to include additional content regarding the patient's condition.