Patient health records

Maintenance and retention of patient health records

A private practice psychiatrist must maintain and retain their patients’ health records in accordance with the privacy and health records legislation in their relevant jurisdiction. They should be aware that legal requirements may vary between jurisdictions.

Refer to:

• MCNZ Maintenance and retention of a patient records
• Documentation, legislation, and storage of patient health records 
• Retention, destruction and disposal of patient health records 

Recording health information

In recording health information about their patients, a psychiatrist should be aware that all health information recorded is subject to privacy law.

Privacy and confidentiality of patient health records

A private practice psychiatrist has responsibility for ensuring the confidentiality, privacy and security of their patients’ health records. For all modes used to communicate their patients’ health information, a psychiatrist should take all reasonable steps to protect patients’ records from misuse, unauthorised access, modification, disclosure, damage, loss and theft.

Refer to:

• MCNZ Use of the internet and electronic communication
• Documentation, legislation, and storage of patient health records
• Retention, destruction and disposal or patient health records 

Privacy and right of access to patient health records

A psychiatrist should be aware that patients are usually legally entitled to access their own health records, obtain a copy, have the contents explained to them and, if appropriate, request correction or amendment. In some circumstances, where there is a risk of serious harm to the patient or others, it may be necessary for a medical practitioner to refuse right of access or to restrict access.

When a patient requests their treating psychiatrist in private practice to provide them with access to their own health record, the psychiatrist should:

• manage the request in accordance with the relevant jurisdictional privacy and health records legislation
• be aware that privacy and health records legislation may vary between jurisdictions
• consider whether it is appropriate or necessary to refuse the request, or restrict access to part of the record only
• explain any cost in the provision of access to records. These costs should fairly reflect the required time to accommodate the request and should not be prohibitive to the patient.

Refer to: Access to patient health records

Request by a legal representative to access patient health records

Psychiatrists should be aware that access to records by a legal representative requires authorisation. The authorising party will be the patient if they have competency. When the patient does not have competency a psychiatrist should refer to the legislated authority in their relevant jurisdiction. Psychiatrists should seek advice from their MDO, as necessary.

Management of subpoenas

A wide range of legislated circumstances exist in which psychiatrists may receive a subpoena for a patient’s health records. When this occurs, a psychiatrist should manage the request by:

• seeking advice from their MDO
• informing the patient of the request, where possible.

Refer to: RANZCP Position Statement 89: Patient–psychiatrist confidentiality: the issue of subpoenas.

Transfer of patient health records

When a patient or another health care provider requests transfer of the patient’s health information to the other health care provider, a psychiatrist should:

• transfer the relevant information when the patient has provided authorisation for the transfer
• note in the patient’s health record the date and the name and address of the individual or organisation to whom the information was transferred.

About this information

For enquiries about this information, contact policy@ranzcp.org.

Disclaimer: This information is intended to provide general guide to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances or information or material that may have become subsequently available.