The Health Records Act 2001 affects all Victorian optometrists, and owners of optometry practices in the State. You need to keep and store all your patient health information and records in accordance with the legislation. Every practice needs to set out in a document its policies on the management of health information, and the steps by which individual patients may obtain access to their health records. These commonly asked questions may help you understand more about this.
Q: Do I have to give a patient a copy of their record if they request it?
Yes. Under the Health Records Act (which applies to both public and private health consultations), and in keeping with the Health Privacy Principles, you must allow patients access to this information on request. This applies regardless of what they intend to do with this information (including if the patient wishes to take it to another practitioner.
The patient is entitled to a full copy or summary of the contents of their record (unless any of the information contained in there was given in confidence by a third party). The patient should not take possession of the original record itself. As a practitioner, you need to retain this record for legal reasons.
Q: Can I charge for the time it takes to copy the record?
You can charge fees for some forms of access, e.g. to cover the costs of copying and time etc. What you are allowed to charge for, and the maximum amount you can charge, is specified in the Health Records Regulations. You can download this document from this website.
http://www.health.vic.gov.au/healthrecords/regs.htm
Q: Do I have to give a patient a copy of their script, if they request it?
Yes, once you are satisfied that this is the correct script for that patient. The Health Records Act requires that you provide patients with a copy of this information if requested, for all information collected after 2001. The Medicare Common Form of Undertaking, which all optometrists sign as a condition of their patients accessing Medicare, also requires that at the end of a fitting process, you must ensure the script is available to the patient.
Q: How long must I keep a patient’s records?
Under Victoria's Health Privacy Principles, records must be kept for seven years. For children (under 18), the record needs to be kept until the patient is 25 years old. We advise that this period of seven years should be taken from the date when you last had any contact in relation to or about that patient (which may be different from the date you last saw them).
In addition to this, Optometrists Association Victoria provides the following advice (consistent with that offered by the providers of our professional indemnity insurance policy):
-
In the case of clinically complex patients, or patients with whom you may have had a more complicated history (including any conflict), records should be kept for a period of 10, rather than seven, years.
-
Again, you should date this from the time you last had contact in relation to or about that patient (which may be different to the date you last saw them).
These requirements also apply to deceased patients.
Destroying old records
Before destroying any old patient records, you need to keep a record of the person's name, their date of birth, the date the patient was first seen, the date the patient was last seen, and the date on which the record was destroyed.
This requirement also applies to deceased patients.
You should destroy the record in a way that complies with all privacy principles, e.g. by shredding the record.
More information on the Health Records Act and Health Privacy Principles, including a full copy of the legislation, is available at the website of the Victorian Health Services Commissioner.
Q: I am selling my practice or retiring, what do I do with my patient records?
In many cases, if you sell a practice it may also make sense to sell the patients' clinical records. Alternatively, you might choose to sell or give them to another local practitioner.
However, if the records are not passed on to another practitioner, then you need to make arrangements to keep them. These records must be kept for the statutory period (and any additional period e.g. as recommended by the provider of your professional indemnity insurance).
The records must be:
-
kept secure, e.g. in a locked facility such as a cupboard or filing cabinet; and
-
under the Health Privacy Principles, they must be able to be accessible on request from former patients.
If your practice does close down, you should let all patients who are in a current course of care or treatment know, and provide information as to how they can access their records. If your records have been sold, you may provide the details of the practitioner who has purchased them. If the records are still in your possession, you may want to set up a postal or email contact for this purpose, and arrange to have it checked on a reasonably regular basis.
Remember: the law says that your patients have a right to access these records, and you may be in breach of the law if you do not put reasonable arrangements in place to facilitate this.
The Health Records Act 2001 affects all Victorian optometrists, and owners of optometry practices in the State. You need to keep and store all your patient health information and records in accordance with the legislation. Every practice needs to set out in a document its policies on the management of health information, and the steps by which individual patients may obtain access to their health records. These commonly asked questions may help you understand more about this.
Q: Do I have to give a patient a copy of their record if they request it?
Yes. Under the Health Records Act (which applies to both public and private health consultations), and in keeping with the Health Privacy Principles, you must allow patients access to this information on request. This applies regardless of what they intend to do with this information (including if the patient wishes to take it to another practitioner.
The patient is entitled to a full copy or summary of the contents of their record (unless any of the information contained in there was given in confidence by a third party). The patient should not take possession of the original record itself. As a practitioner, you need to retain this record for legal reasons.
Q: Can I charge for the time it takes to copy the record?
You can charge fees for some forms of access, e.g. to cover the costs of copying and time etc. What you are allowed to charge for, and the maximum amount you can charge, is specified in the Health Records Regulations. You can download this document from this website.
http://www.health.vic.gov.au/healthrecords/regs.htm
Q: Do I have to give a patient a copy of their script, if they request it?
Yes, once you are satisfied that this is the correct script for that patient. The Health Records Act requires that you provide patients with a copy of this information if requested, for all information collected after 2001. The Medicare Common Form of Undertaking, which all optometrists sign as a condition of their patients accessing Medicare, also requires that at the end of a fitting process, you must ensure the script is available to the patient.
Q: How long must I keep a patient’s records?
Under Victoria's Health Privacy Principles, records must be kept for seven years. For children (under 18), the record needs to be kept until the patient is 25 years old. We advise that this period of seven years should be taken from the date when you last had any contact in relation to or about that patient (which may be different from the date you last saw them).
In addition to this, Optometrists Association Victoria provides the following advice (consistent with that offered by the providers of our professional indemnity insurance policy):
-
In the case of clinically complex patients, or patients with whom you may have had a more complicated history (including any conflict), records should be kept for a period of 10, rather than seven, years.
-
Again, you should date this from the time you last had contact in relation to or about that patient (which may be different to the date you last saw them).
These requirements also apply to deceased patients.
Destroying old records
Before destroying any old patient records, you need to keep a record of the person's name, their date of birth, the date the patient was first seen, the date the patient was last seen, and the date on which the record was destroyed.
This requirement also applies to deceased patients.
You should destroy the record in a way that complies with all privacy principles, e.g. by shredding the record.
More information on the Health Records Act and Health Privacy Principles, including a full copy of the legislation, is available at the website of the Victorian Health Services Commissioner.
Q: I am selling my practice or retiring, what do I do with my patient records?
In many cases, if you sell a practice it may also make sense to sell the patients' clinical records. Alternatively, you might choose to sell or give them to another local practitioner.
However, if the records are not passed on to another practitioner, then you need to make arrangements to keep them. These records must be kept for the statutory period (and any additional period e.g. as recommended by the provider of your professional indemnity insurance).
The records must be:
-
kept secure, e.g. in a locked facility such as a cupboard or filing cabinet; and
-
under the Health Privacy Principles, they must be able to be accessible on request from former patients.
If your practice does close down, you should let all patients who are in a current course of care or treatment know, and provide information as to how they can access their records. If your records have been sold, you may provide the details of the practitioner who has purchased them. If the records are still in your possession, you may want to set up a postal or email contact for this purpose, and arrange to have it checked on a reasonably regular basis.
Remember: the law says that your patients have a right to access these records, and you may be in breach of the law if you do not put reasonable arrangements in place to facilitate this.