My Health Record content

Under the My Health Records Act 2012, a Shared Health Summary can only be authored/created by a consumer’s Nominated Healthcare Provider. This person is usually the consumer’s usual GP or another health provider who usually provides care to the patient. A Nominated Healthcare Provider must be a medical practitioner (not necessarily a GP), a registered nurse, or an Aboriginal or Torres Strait Islander health practitioner who has a Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care (Practice). The decision about whether this person is the consumer’s Nominated Healthcare Provider is decided by mutual agreement between the consumer 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.

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
• when completing a patient health assessment – for example, a GP management plan or child health check
• when there has been a change to a patient’s medical conditions, medicines, allergies, adverse reactions or immunisations.

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 Share 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.

Documents in a person’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 care to upload an updated Shared Health Summary when there is a change to a patient’s medical conditions, medicines, allergies, adverse reactions or immunisations.

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 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.

An Event Summary should contain enough information to appropriately communicate the change or action taken. The information should be presented in such a way that it can be easily understood by another healthcare provider.

No. As an Event Summary details a single healthcare event, it’s possible that a patient may have multiple Event Summaries. The healthcare provider who created and uploaded the Event Summary can delete it if it contains a mistake or was uploaded in error. 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.