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Record-keeping and Patient Control Over Medical Documents

Introduction

With the advent of modern technology, we have become so used to deleting a photo or post with a quick tap. But it is quite a different story when it comes to healthcare.

Record-keeping and patient control over medical documents are integral to Australian laws, which are primarily aimed at protecting patients and medical practitioners.

When a doctor issues a medical certificate, it becomes a formal clinical record, helping ensure that relevant clinical records are retained in accordance with legal requirements when needed for healthcare, administrative, or legal purposes.

This guide explains how medical certificates remain confidential and protected, the legal data retention standards in Australia, and your rights and obligations regarding access to and management of your health records.

This issue is very much related to our security measures. Please refer to our Digital Signatures and Verification document for details on verifying stored documents.

The Importance of Record Keeping in Healthcare

Equally accurate record-keeping is not merely a formality; it is a fundamental safety standard.

1. Continuity of Care

If you visit a different doctor the following year, having a record of your past diseases, allergies, and medications may help the doctor make informed clinical decisions.

2. Legal Protection

Medical certificates may be relied upon as supporting documentation in administrative or legal contexts, depending on the circumstances. The clinic record may be used to support the certificate if its validity is later queried.

3. Regulatory Compliance

Doctors under the Health Practitioner Regulation National Law have a legal obligation to keep detailed, accurate records of all patient visits. Failure to maintain appropriate records may raise professional and regulatory concerns under applicable healthcare laws and standards.

We do not take these duties just as mere formalities. Learn more about our standards for suitability and legal compliance in the sections below.

How Long Are Medical Certificates Kept?

One frequently asked question is whether a medical record is a permanent record in the system.

Under Australian privacy and health records legislation, including state-based health records laws, providers are legally obligated to retain data for a specified period.

In many Australian jurisdictions, medical records are required to be retained for a minimum period, commonly around 7 years for adults, and longer for children, depending on applicable laws and circumstances.

The information must be kept in a secure location and made available to the patient if required during the retention period. Once the time allowed by the law has elapsed, the data may be securely discarded or de-identified.

While you have significant rights regarding access and consent, medical records are managed within a regulated legal framework. Check out how we handle your data privacy and patient document access, or review our privacy policy.

Who is in Control of Medical Records?

There have been quite a few controversies over the question of medical record "ownership".

  • The Doctor/Clinic: The entity that physically or digitally holds the file (the "record" itself). They act as custodians because they are responsible for its security.
  • The Patient: Possesses a legal right of access to the information contained within the record and the power to decide who gets to see it.

In short, although you cannot physically take the server or a hard drive, you have the right to control who you authorise to access your health information, within legal limits.

This framework is designed to support the Patient Privacy Act 1988 and appropriate control over personal health information. Visit our privacy page for details on OAIC standards, or go to the legal compliance section for ownership laws.

How Patients Can Request Record Access or Removal

Requesting Access

You're free to request a copy of your medical certificate or a consultation summary at any time.

  • Self-Service: You are always welcome to access your Prime Medic account and download any documents stored there.
  • Formal Request: If your records are older, contact the support team. You may be asked to provide your ID to verify that the right person is accessing the data.

Requesting Removal (Deletion)

Patients, at times, are inclined to ask for a total "delete" of everything."

  • Account Deactivation: When you deactivate your account, you will no longer be able to log in.
  • Clinical Record Deletion: In most cases, healthcare providers must retain clinical records for a legally mandated period and therefore cannot delete them upon request.

Tip: You are entitled to request a change or attach a comment to the document if you believe that the record is inaccurate (e.g., information you consider to be incorrect or incomplete).

If you need support with your records, please visit our Help Centre or review our privacy protocols.

Prime Medic's Record Management Framework

When handling your highly confidential documents, we take a "Security by Design" approach.

  • Encryption: Records are stored and transmitted using encryption and other security measures to protect patient information.
  • Audit Logs: The system records every time that a user opens a record, creating an audit trail that helps deter and identify unauthorised access.
  • Sovereignty: Health data is stored in secure hosting arrangements that comply with Australian privacy and health information laws.

The essential factor is trust. Review our quality compliance and privacy sections for more information about our secure infrastructure.

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