Shared health summary
A shared health summary is a clinical document in My Health Record providing an overview of specific health information about the patient at a particular point in time. It includes information about the patient’s:
- current medicines
- past medical history
- allergies and adverse reactions
- immunisations/vaccinations.
Under the My Health Records Act, a shared health summary can only be created by a patient’s nominated healthcare provider. Typically, this person is the patient’s usual GP or another healthcare provider who provides them with regular care.
The nominated healthcare provider must be:
- a medical practitioner
- a registered nurse, or
- an Aboriginal and/or Torres Strait Islander health practitioner who has a Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care (Practice).
A patient’s nominated healthcare provider is decided on by mutual agreement between the patient and the healthcare provider. Only one person can serve as the nominated healthcare provider at any given time.
It is important to note there are no technical constraints built into My Health Record to restrict any authorised healthcare provider from creating and uploading a shared health summary.
A shared health summary can be created during any consultation. The nominated healthcare provider may feel it is useful to create and upload a new shared health summary when:
- completing a patient health assessment (for example, a GP management plan or health check)
- there have been significant changes to a patient’s medical conditions, medicines, allergies, adverse reactions or immunisations.
The information within a shared health summary is similar to the information found within a GP health summary. The time it will take to create a shared health summary will depend, in part, upon the quality and currency of the information already available in the patient's local medical record. It will also depend on the complexity of the patient's health conditions and management.
If the nominated healthcare provider believes omitting certain information from the document on the request of a patient might mislead other healthcare providers, they may decline to upload the shared health summary to the patient’s record.
Once a shared health summary has been created, the patient’s nominated healthcare provider can upload the summary to My Health Record from their clinical information system.
While it is best practice to do so, there is no legal requirement for a healthcare provider to give a patient the opportunity to review their shared health summary prior to uploading it to My Health Record.
Documents in a patient’s record cannot be edited. The only way to update a shared health summary is by creating and uploading a new one.
Event summary
An event summary is a standalone document in My Health Record which provides information about a healthcare event relevant to a patient's ongoing care (for example, a clinical intervention, treatment commencement or cessation, or a change in clinical status).
An event summary can be created when a significant healthcare event has occurred, or where there has been a change in a person’s health status, but it is not appropriate to create a shared health summary.
Typically, event summaries are created and uploaded to My Health Record in situations where a patient is seeing a healthcare provider who is not their usual GP. Creating and uploading an event summary does not replace the need for the relevant healthcare provider to communicate directly with the patient’s usual GP or general practice.
An event summary should contain sufficient information to appropriately communicate a change in a person’s health, along with any further observations or actions taken by the relevant healthcare provider. The information should be presented in such a way that it can be easily understood by another healthcare provider.
Event summaries contain a free text field to provide a clinical synopsis and may include information on the patient’s:
- allergies and adverse reactions
- medicines
- diagnoses
- interventions
- immunisations/vaccines
- diagnostic interventions.
Any authorised healthcare provider who is working in a participating healthcare organisation can create and upload an event summary.
Situations where it might be appropriate to create an event summary for a patient include where the patient:
- is receiving care from an after-hours GP service
- is transient/holidaying
- is receiving an immunisation/vaccine from someone other than their usual GP.
An event summary that has been uploaded to My Health Record cannot be edited. If there is a mistake in the summary or it was uploaded in error the healthcare provider who created and uploaded the event summary can delete it. A new event summary can then be uploaded.