Viewing a My Health Record
Medical practitioners who decide to use the My Health Record system are free to apply their clinical judgement to determine when and how they will use the system.
Once a patient's Individual Healthcare Identifier (IHI) has been downloaded in to your clinical software, you can start accessing and uploading information to their My Health Record.
Any person involved in an individual's healthcare and who is authorised by the healthcare organisation, can access a My Health Record. Access is not limited to clinicians with HPI-Is.
No. You do not need the consent of an individual to view their record, and you can access an individual's record outside of a consultation, provided that access is for the purpose of providing healthcare to the individual.
Individuals may however choose to enable My Health Record privacy settings to control which healthcare organisations can access their My Health Record. They can limit access to their entire record (using a Record Access Code) or to particular documents (using a Limited Documents Access Code). The patient will need to provide their access code to a provider for them to access their My Health Record when prompted by their clinical software to do so (unless it is an emergency situation in which case a provider can use the emergency access functionality). See myhealthrecord.gov.au for more information about privacy controls.
Currently the number of individuals opting to use these privacy settings is fewer than 2 out of every 1000 individuals registered, and where an individual has opted to use privacy settings, healthcare organisations do not have to be granted access to a My Health Record in order to upload to it.
- For more information, please visit Patient Access Controls.
A provider is under no legal obligation to use the My Health Record system. It is up to the healthcare provider and his or her clinical judgement as to when and how they use the system. However, examples of when it might be relevant to see if a patient has a My Health Record are outlined below.
If the patient is visiting you for the first time
If a new patient presents to you, there could be information from multiple sources in their My Health Record to support your understanding of their needs. For example:
- A Shared Health Summary from their prior nominated healthcare provider giving information of their medicines, allergies, immunisations and medical history.
- A record of the patient's prescribed and dispensed medicines.
After hospital discharge
- The hospital may have uploaded a discharge summary providing details of the patient's stay. This could include clinical synopsis, interventions, diagnosis, medicines and diagnostic imaging results.
After an after-hours GP visit
- If your patient visited an after-hours GP service, the GP may have thought the visit warranted uploading an Event Summary to the patient's My Health Record.
- The GP may also have prescribed new medicines which could be listed in the patient's record.
After an incident on holiday
- If the patient had an incident on holiday in Australia and saw a different clinician, that clinician may have uploaded an Event Summary outlining the incident and treatment provided.
- The patient's prescribed and dispensed medicines may also have changed due to the incident, which could be visible in their My Health Record.
After the patient has seen a specialist
- The specialist may have uploaded a Specialist Letter providing details of the diagnosis. This could include the specialist's recommendations, medicine review and diagnostic investigation results.
After the patient has had a community nursing visit
- The nurse may have uploaded an Event Summary to the patient's My Health Record if the nurse thought it useful.
After an aged care respite stay
- The Residential Aged Care Facility may have uploaded an Event Summary outlining any significant event occurring while the patient was in respite. The Event Summary could include medicines, diagnosis, interventions and any other information the healthcare provider thought relevant.
In an emergency situation
- In an emergency situation, the patient's My Health Record could give you information about the patient's known allergies, medicines, immunisations and medical history in a Shared Health Summary.
Patient has entered information in to their My Health Record
- A patient may tell you they have a My Health Record, in which they have entered information about the current medicines they're taking or their known allergies and adverse reactions. In this instance the patient's My Health Record may support your medication assessment.
For more information about each of the clinical documents mentioned above, see Clinical Documents.
Clinical software products, which include My Health Record system functionality, will all look slightly different. However, the Agency recommends that a My Health Record Status Indicator be displayed obviously and prominently for clinicians in their clinical software. For individuals who have not applied additional privacy settings to their My Health Record, this mechanism will enable healthcare providers to know whether the patient has a record.
It may also be useful to have a conversation with your patient about what is involved in having a My Health Record and the benefits it could provide.
While clinical software products will all look slightly different, in the majority of cases clinical documents are presented in a document list.
There is a series of online demonstrations showing how simple it is to viewing clinical documents in a patient's My Health Record.