Health professionals will collect a lot of information about your health and the treatment you receive. A medical record contains personal information, so it’s important to know who can see it, change it and copy it. This section covers your rights in relation to your medical records and other privacy issues, such as talking about sensitive matters with health professionals.
It’s important to note that your rights may vary depending on which state or territory you live in. For specific information, contact the Office of the Australian Information Commissioner (oaic.gov.au), talk to your treatment team, or seek independent legal advice.
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When you are treated for a medical condition, either in or out of hospital, the person treating you creates notes about your health. This is called a medical record. It can be handwritten or electronic.
What does a medical record include?
- services provided
- scans, tests and the interpretations of results
- recommendations about treatments
- personal details (e.g. genetic information)
- correspondence to health professionals.
Every treatment centre you attend will keep a medical record about you, and they will add to that record each time you visit or have tests.
Who owns my medical records?
The treatment centre or health professional who creates a medical record owns and maintains the record.
Australian law considers ownership and access as separate – so although you don’t own the medical record, you can request access to it.
Different states and territories may have different requirements about how long doctors and treatment centres must keep your records after your last consultation.
Who can access my medical records?
Australian privacy standard establish a general rule that organisations are required to provide you with access to personal information (such as medical records) held about you.
This standard has been developed because giving people access to their medical records:
- allows them to better understand their condition and treatment
- can help ensure the information is accurate
- may make people feel more confident about the health care system.
You can authorise someone else to see your medical records, such as a relative, interpreter or another health professional.
Your records may also be provided to the health ombudsman if you make a complaint about your health care.
How can I access my medical records?
If you would like to see your medical records, ask your health care provider (e.g. GP, specialist, hospital or treatment centre) for access.
You may have to put the request in writing and provide proof of identity, such as a driver’s license or birth certificate.
There is no set time limit for a health care provider to meet a request for medical records. However, the Office of the Australian Information Commissioner recommends that a request should be processed within 30 days.
The health care provider may charge a fee to copy your record (public hospitals usually charge about $30), but there shouldn’t be a fee to just look at the record.
Why might access be denied?
Rarely, you won’t be allowed to have a copy of your medical records because:
- another law requires your information to be kept private (e.g. if the information relates to legal proceedings)
- there’s a risk that the information could harm you or someone else, such as a relative, treatment staff or other patients.
Who can change my medical records?
You can ask for changes to your medical records if you think the records are inaccurate, irrelevant or misleading. You should make this request in writing.
If a treatment centre refuses to change your medical record because they think it is correct as it is or that your suggested changes are not appropriate, it must provide a written explanation for the decision.
If you disagree with the decision, you can make a complaint to the Office of the Australian Information Commissioner or to the health ombudsman or complaints commission in your state or territory.
Other privacy issues
When you are having treatment, you have a right to privacy and confidentiality. Some privacy issues that may affect you include:
- If you’re being treated in a public hospital, you have the right to talk to your doctor in a quiet, private room. You can also decide who should be included in the meeting.
- You can decline visitors, even during hospital visiting hours.
- In some treatment centres, trainee doctors and medical students observe consultations and are involved in cancer care under the supervision of a specialist. You should be informed if they will be involved, and you are entitled to refuse or limit their involvement.
- You can ask your doctor or treatment centre to mail information to you in unmarked envelopes.
If you’re concerned about your privacy, talk to your treatment team or hospital social worker.