When you arrive at the practice, you see Vicky*, the receptionist sorting a patient’s file. On enquiry, Vicky explains that Jane*, a 32-year-old patient who is relocating to another town, called earlier to urgently request that her medical records are transferred to her new specialist in that town. Vicky has already faxed several pages to the specialist. You ask her which medical records Jane has requested and to whom they are being released?
Vicky explains that she confirmed Jane’s full name and current address, and has documented her verbal request for the transfer of her medical records in Jane’s medical records, and the name of the specialist the medical records are being sent to. Vicky has also sent a cover fax to the specialist detailing Jane’s request. After checking that this request has been documented in Jane’s medical records and the pages being sent, you are happy to allow the remaining pages to be faxed to the specialist.
All doctors have an ethical and legal duty to ensure medical records are kept confidential. However, doctors receive requests for access to medical records and are often unsure of their responsibilities for sharing confidential information. Requests for access may come from the patient themselves, from another person or organisation, or via a court order.
You can share medical information with a third party if you have authority from your patient or you are required to by law.
In each instance, before sharing patient records, consider:
1. Requirements for consent
Ideally, the consent should:
Be in writing, signed and dated by the patient
- If verbal consent obtained, document the details discussed
- Indicate which records and to whom they can be released
- Be reasonably current i.e. not more than 12 months old.
2. Your legal obligation
Examples where legislation requires you to share health information without express authority from the patient include:
- Public health requirements to report infectious diseases
- Summons or subpoena to produce medical records to a court or tribunal
- A police search warrant.
3. Which documents to supply
Read the request and the patient’s authority carefully to ensure that you know:
- Which documents to include
- Which documents to exclude.
An insurer may request all the patient’s medical records, but the patient may only authorise disclosure of records relevant to the insurance claim.
Consider confirming consent with the patient, particularly if the patient’s records contain sensitive material as the patient may not have considered the implications of releasing this information.
Letters from specialists should be shared with the patient or third party even if the specialist has not provided specific consent, and even if the letter says it should not be disclosed to the patient or third party without the writer’s consent. Such notifications do not overcome the legal requirement under privacy laws giving patients, subject to certain exceptions, the right to access to their health information.
4. Refusing to provide information
There may be occasions when you are concerned about providing records to a third party, even with appropriate authority or legal requirement. In certain circumstances, for example, a situation in which supplying the records may result in significant harm to an individual, it may be possible to withhold records from disclosure – contact Avant for advice if you have any concerns.
- Document any conversations you have with the patient
- Carefully read the request for medical information and the patient’s authority to ensure the correct documentation is shared and that it is within the scope of the patient’s authority
- Understand that sometimes you are legally required to share information with a third party without express authority from the patient
- Know that you can refuse to provide records in certain circumstances
*This scenario has been created based on Avant’s Medico-legal Advisory Service and claims experience.
For more information, watch this video Managing requests for medical records on the Avant Learning Centre.
Find out more
For more advice regarding sharing medical records, call Avant’s Medico-legal Advisory Service on 1800 128 268.
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