Medical Records

All our clinical records are stored in Best Practice. Our practice discourages the use of paper records and requests that all staff type their clinical notes into Best Practice

Patient identifying data is routinely collected on our patient registration form. Our registration form requires the patient to fill in details of who they wish to be contacted in the case of an emergency. Any missing details from this form are filled by clinical staff. All new patients are required to have an initial assessment by our practice nurse to ensure that this information is complete and recorded in our clinical software.

Access to the clinical software (Best Practice) on a site level is determined by the access level as set up and managed by the practice manager. In the setup phase for a new staff member, the access levels for the clinical and administrative software (Total Care) packages are solely determined by the user’s clinical and business function.

To ensure each user has the correct access to the clinical software package the permissions given during the setup phase are ‘Inherited’ from an existing user that works within the same (or similar) role as determined by the position description ie. an employee doctor, practice nurse, allied health staff member.

For the administrative package, the user set up requires access to ‘modules’ to be selected at the time of user set up, and these should again mirror that of an existing staff member holding the same position.

Only the practice manager and clinical director have the ability to grant access to varying levels of permission. In the event neither of the aforementioned are able to vary access levels for a particular user, inquiries are to be directed to the Practice computer security coordinator for further consideration.

If medical records are lost or damaged, these may be constructed using the data held on the computer backup network systems. Refer to Information Security (Criterion C6.4) in the RACGP Standards for general practices 5^th edition and the RACGP Computer and information security standards.