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2022 RACGP curriculum and syllabus
for Australian general practice
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Privacy and managing health information in general practice
Express consent should be sought wherever practical and/or where significant clinical risk is possible (eg before a procedure or surgery). A signed form is an example of express consent, but an informed and well-documented discussion with a patient might equally comply with this requirement.
Inferred consent should only be used when express consent cannot be obtained. GPs must not overestimate the scope of inferred consent. For example, it is reasonable to infer a patient’s consent to their records being collected and used during repeat consultations. However, this consent would not necessarily extend to the disclosure of that information to third parties; for example, sharing health summaries within referral letters to other medical professionals.
GPs should also be wary of taking silence or a lack of objection as an indicator of consent; if there is any doubt, GPs should obtain express consent.
It is recommended consent conversations are thoroughly documented, within a patient’s medical record. Problems might arise if a patient does not understand the potential uses of their health information. Where GPs must establish implied consent, comprehensive consultation notes are essential. These notes should include the information provided, the nature of the discussion and the patient’s response.