Other Information and Organisation Professionals
This unit group covers Information and Organisation Professionals not elsewhere classified. It includes Company Secretaries, Cost Controllers, Health Information Managers, Patents Examiners and Records and Information Managers.
Who gets to see the record
You are a health information manager at a hospital, responsible for keeping patient records accurate, accessible to those who need them and private from those who do not. It is Tuesday morning. Requests for patient records are arriving from all directions, the system is being upgraded and a handful of people expect you to bend the rules for them.
Choose what you would do. Then see what happens. There are often good reasons for each choice.
I need to look at a patient's history before my clinic starts. She isn't mine, but I know her family and I'm worried about her. It'll only take a minute. Can you open her file for me?
Open it for her, because she is a senior doctor, her intentions are good and it would only take a moment before her clinic starts
Records are for people providing care to that patient, however kind the intention. You have set aside the rules and the patient's trust. Seniority does not change who may see a record.
Explain the rule kindly, offer to ask the patient's treating team or the patient themselves, and suggest how she can help
Dr Fernandez is disappointed but understands. She passes her concern to the treating team, who follow up. You protected the patient and still helped.
Say no firmly and tell her she should know better
The rule is upheld, but she feels scolded and avoids you after that. You can protect privacy without turning a good intention into an insult.
I'd like a copy of everything in my medical record from my stay last year. The nurse at the desk said I'd have to fill in forms and wait weeks. Is that right? It's my own information.
Tell him the nurse was right and that the process is long, so he should be patient
He nods, but leaves frustrated. The process may take time, but he can be told what each step involves and how long it should take.
Give him a printout right now to avoid delay, without the usual identity check, because he is clearly the man in the file
You have handed out private information without checking who he is. If he were someone else, you would have caused serious harm. The identity check exists for a good reason.
Explain his right to his own record, help with the identity check and forms and tell him what to expect
Mr Baptiste understands each step, and the process moves smoothly. He thanks you for treating his request as normal and reasonable, which it is.
We need to switch to the new records system on Friday. Some old paper files haven't been entered. Can we just archive those without checking them? We'll sort out gaps afterwards.
Agree, to keep the project on schedule
Files that were not entered become hard to find, and a clinician cannot locate an older record when it matters. A missing record can affect real care.
Delay the switch until every old file is entered, whatever it takes
The records are safe, but the project stalls and the old system stays in place longer. Perfection has a price, and you could have made a plan that kept both going.
Agree to the date only if the old files are sorted by priority and an access plan is in place for the rest
Sandy agrees. The files clinicians use most are entered first, and the rest are findable and tracked. The switch happens with no gaps that matter.
How it went
At the end of the day, records are where they should be, private from those with no reason to look and open to those who need them. Health information work is quiet and exact, and it protects people when they are at their most vulnerable. Does that kind of careful guardianship appeal to you?
This is a simplified, fictional situation to help you explore. It is not professional instruction or a test of your ability.
Case study: The record that someone was curious about
A fictional case set in the health information department of a fictional regional hospital.
The situation
Odette was the health information manager at Brindle Valley Hospital. During a routine check of who had opened which patient records, she noticed that a staff member from a different department had looked at the file of a well known local sportsman who had been in for a minor procedure. The staff member had no reason to see it. Nothing had been shared or copied, and the person was well liked and had worked at the hospital for years. Reporting it would make life awkward for a lot of people.
What they did
Odette followed the hospital's process. She documented what she had found without drawing conclusions, spoke to her own manager and the privacy officer, and made sure the staff member's manager heard the facts before any conversation with the person. The staff member was given a chance to explain. Odette also asked the team to think about why the system had allowed the access so easily, and suggested a pop up reminder before records can be opened.
How it turned out
The staff member admitted it was curiosity, received formal counselling and training, and stayed in the role. The patient was informed in line with hospital policy. The reminder was added to the system, and the number of unusual access alerts dropped in the months afterwards.
What would you do?
- Why does it matter that nothing was shared with anyone?
- How would you feel reporting a colleague you like?
- What do you think patients expect when they trust a hospital with their information?