My Health Record content
Content added by healthcare consumers
|Personal Details||Includes Aboriginal and/or Torres Strait Islander status and veteran/Australian Defence Force (ADF) status|
|Emergency contact details||Next of kin/carer contacts|
|Advance Care Planning Document||A statement regarding a person’s preferences for their future medical treatment or health outcomes and may formally appoint a substitute decision-maker. It may or may not have legal standing/be legally binding.
Click here to read the National Guidelines for the use of My Health Record to store and view Advance care planning documents.
|AdvanceCare Document Custodian||Name of the person and/or organisation who holds a copy of the individual’s advance care planning document(s)|
|Personal Health Summary||Health details the individual wishes to share with their healthcare providers, such as allergies/adverse reactions and current medicines|
|Personal health notes(not visible to healthcare providers)||Private diary entries – cannot be viewed by healthcare providers|
|Childhood development information||Information entered by the parent (or any other authorised representatives) about the child’s health and development|
Content added by general practice
|Shared Health Summary||A clinical document that represents the patient’s health status at a particular point in time. It may include information about a patient’s medical history in four key areas, including, medical conditions, medicines, allergies/adverse reactions and immunisations. It can only be created by a patient’s nominated healthcare provider.
An example of what a Shared Health Summary looks like can be found here
|Event Summary||An event summary captures key health information about significant healthcare events that are relevant to the ongoing care of an individual. An event summary may be used to indicate a clinical intervention, improvement in a condition or that a treatment has been started or completed.
An event summary may contain, allergies and adverse reactions, medicines, diagnoses, interventions, immunisations and diagnostic investigations. An example of what an Event summary looks like can be found here.
|Prescription Records||Prescription records contain information about medicines prescribed by a healthcare provider, including the prescriber’s name and the healthcare organisation visited. It may also include generic medication name, dosage instructions, maximum number of repeats, and the date the medication was prescribed.
An example of what the medicines information view looks like can be found here.
|eReferrals||eReferral documents facilitate the transmission of significant patient information from one treating healthcare provider to another for the purpose of making a request for further diagnosis or treatment. They have a specified structure, including fields for current and past medical history, current medications, allergies and/or adverse reactions, and diagnostic investigations (optional). An eReferral includes a free-text “reason for referral” field for the referrer to include additional content about the patient’s clinical background.
An example of what an e-Referral looks like can be found here.
Content added by other healthcare providers
|Pathology report||Can include blood tests and biopsies from participating pathology practices. Click here for a list of the pathology providers currently able to upload reports to My Health Record.
Some private pathology providers have special requirements to enable results to be uploaded to My Health Record including eOrders and activation of report uploads. More information can be found here.
Once these requirements are met, the reports will be uploaded and your patient will be able to read the report after 7 days (except for COVID-19 pathology reports which are available after 24 hours). This gives doctors time to check the report first and contact the patient about the results, if needed.
|Diagnostic imaging report||X-ray and scan reports from participating diagnostic imaging providers. Click here for a list of the diagnostic imaging providers currently able to upload reports to My Health Record.|
|Event Summary||An event summary captures key health information about significant healthcare events that are relevant to the ongoing care of an individual. Other healthcare providers, such as private Specialists and Allied Health Providers can upload an Event Summary.|
|Specialist letter||When a specialist letter is created, structured fields, including standard (optional) fields, give the sender the ability to include information about patient recommendations, medications and medication review, adverse reactions and diagnostic investigations. Includes a free-text “response narrative” field for the specialist to include additional content about the patient’s condition.|
|Prescribe and dispense information||A prescription record contains information about medicines prescribed by a healthcare provider. A dispense record contains information about medicines dispensed by a pharmacist. You can view information about the healthcare provider that prescribed the medicine and the pharmacist and the pharmacy where the medicine was dispensed.
These prescribed records may include:
The dispensed information includes:
|Discharge summary||When a healthcare provider creates a discharge summary, it will be sent directly to the intended recipient, as per current practices. When a hospital is connected to the My Health Record system, a copy of the Discharge Summary can also be sent to the patient’s My Health Record. Click here for a list of the public hospitals registered to use the My Health Record.
An example of a discharge summary can be found here.
|Pharmacist Shared Medicines List (PSML)||A document that is created and uploaded by a pharmacist and includes a list of medicines a consumer is known to be taking including prescribed, over-the-counter and complementary medicines at the time the list is created.|
Content added by Medicare
|Medicare Benefits Schedule (MBS) claims information||The fields displayed are the date of service, the item number, the description of the service, the service provider, and whether it was an in-hospital service. The contents of the service are not displayed. Medicare information is collected by Services Australia and/or the Department of Veterans’ Affairs (DVA) and is available on My Health Record. On first access of a record, up to two years retrospectively of Medicare information may be available.|
|Pharmaceutical Benefits Scheme (PBS)/Repatriation PBS (RPBS) claims information||Provides information about medicines that have been claimed for the patient under the PBS. When a My Health Record is activated, two years of retrospective PBS/RPS data appears.|
|Immunisation records||This includes a list of immunisations that have been recorded on the Australian Immunisation Register (AIR).|
|Organ donor status||Supplied by the Australian Organ Donor Register (AODR).|
Shared Health Summary vs Event Summary
|Shared Health Summary||Event Summary|
|What is it?||Represents the patient’s health status at a point in time.||Captures key health information about a significant healthcare event that is relevant to the ongoing care of the patient, e.g. indicating a clinical intervention, improvement in a condition or treatment has been started or completed.|
|What does it contain?||This will include known information in four key areas (mandatory fields):
||Optional content (select/unselect as required):
|Who can create it?||Can only be authored by a patient’s ‘Nominated Healthcare Provider’ (as defined in the My Health Records Act 2012) – usually a health practitioner who has ongoing contact with the patient.||Any eligible healthcare provider.|
Who can create a Shared Health Summary?
Under the My Health Records Act 2012, a Shared Health Summary can only be authored/created by a patient’s Nominated Healthcare Provider. This person is usually the patient’s usual GP or another healthcare provider who usually provides care to the patient. A Nominated Healthcare Provider must be a registered medical practitioner (not necessarily a GP), a registered nurse, or an Aboriginal and Torres Strait Islander health practitioner with a Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care. The decision about whether this person is the patient’s Nominated Healthcare Provider is decided by mutual agreement between the patient and the healthcare provider. Only one person can serve as the Nominated Healthcare Provider at any given time. An example of what a Shared Health Summary looks like can be found here
When can a Shared Health Summary be created?
A Shared Health Summary can be created in the context of any consultation. A Nominated Healthcare Provider might feel it is useful to create and upload a new Shared Health Summary in the following situations:
- where a Shared Health Summary does not already exist, perhaps at the request of the patient
- where a patient has one or more chronic medical conditions and needs a GP management plan
- when completing a patient health assessment , for example, a 75+ health assessment or child health check
- when there has been a change to a patient’s medical conditions, medicines, allergies, adverse reactions or immunisations.
How is a Shared Health Summary created?
The information in a Shared Health Summary is pulled from the patient’s record in your clinical information system. The better the quality and currency of the data in your local files, the easier it will be to create a Shared Health Summary. The RACGP has developed the resource Improving health record quality in general practice to assist GPs to maintain good quality patient records that are fit for purpose.
If a patient explicitly asks a healthcare provider not to upload information to their My Health Record, the healthcare provider must comply with that directive. Therefore, a patient can request that information be left out of a Shared Health Summary or for a Shared Health Summary to not be uploaded altogether. However, if the Nominated Healthcare Provider believes that omitting the information might mislead other healthcare providers, they may decline to upload the Shared Health Summary that omits the information. There is no legal requirement for a healthcare provider to give a patient the opportunity to review the Shared Health Summary prior to upload. Once the Shared Health Summary has been created, the Nominated Healthcare Provider uploads the document to My Health Record from their clinical information system.
How is the information in a Shared Health Summary updated?
Documents in a patient’s My Health Record cannot be edited. The only way to update the Shared Health Summary is by creating and uploading a new Shared Health Summary. The healthcare provider who created and uploaded the Shared Health Summary can delete it if it contains a mistake or was uploaded in error. Although there is no legal requirement to regularly update a Shared Health Summary, it is useful for the patient’s carer to upload an updated Shared Health Summary when there is a change to a patient’s medical conditions, medicines, allergies, adverse reactions or immunisations.
When can an Event Summary be created?
An Event Summary might be created for a patient who is receiving care from an after-hours GP service, a transient/holidaying patient, or a patient who is receiving an immunisation/vaccine from someone other than their regular GP. Unlike a Shared Health Summary, an Event Summary may be used to indicate a clinical intervention, improvement in a condition or that a treatment has been started or completed. An Event Summary can be created by any healthcare provider including Allied Health practitioners such as a physiotherapist or a psychologist. In all of these cases, the same information should be sent directly to the patient’s usual GP or general practice as well.
An example of what an Event Summary looks like can be found here.
How is an Event Summary created?
An Event Summary should describe and summarise the presentation of the event, the assessment made, and the action taken. As per standard practice, all clinically relevant information should be recorded and saved in the patient’s local notes.
Can an Event Summary be updated?
An Event Summary details a single healthcare event, therefore it’s possible that a patient may have multiple Event Summaries. The healthcare provider who authored and uploaded the Event Summary can edit or delete it if it contains a mistake or was uploaded in error. The edited document will supersede the original. Creating and uploading an Event Summary does not replace communicating directly with the patient’s usual GP or general practice to inform them about the contact with the patient.