Healthcare providers can upload a copy of prescribed or dispensed medicines to a patient's My Health Record.
What are prescription and dispense records?
Prescription and dispense records contain information about medicines prescribed by a healthcare provider. The records also provide details about the healthcare provider that prescribed the medicine and the healthcare provider organisation that was visited.
These records may include:
- medication brand name and strength prescribed
- generic medication name
- dosage instructions
- maximum number of prescription repeats
- the date the medication was prescribed and the prescription expiry date
These records can be viewed in the My Health Record system as clinical documents and are also displayed in the Prescription and Dispense View of the system and in the Medicines Information View, so that individuals and their healthcare providers can easily view details of their prescribed and dispensed medicines.
The Prescription and Dispense View can display the name of a medicine (both the brand name as well as the active ingredients), the strength of the medicine (e.g. 2mg, 20mg, etc.), the direction for consumption (e.g. take one capsule daily) and the form of the medicine prescribed (e.g. capsule, tablet, inhaler, etc.). It can also display the date a medicine has been prescribed, the date it has been dispensed, and the number of repeats available on the prescription.
Who can upload a prescription or dispense record?
Healthcare providers who use conformant clinical software to prescribe medicines (e.g. a general practitioner) or dispense medicines (e.g. a pharmacist) can upload a copy of this information to a patient's My Health Record.
How do I upload a prescription or dispense record?
Sharing of prescription and dispense information to a patient's My Health Record is intended to be streamlined and form part of your workflow.
By default, if a patient has a My Health Record, the prescription and dispense record will be uploaded, provided the patient’s details are recorded within your clinical information system (first and last name, gender, date of birth and Medicare number, including reference number, or Department of Veteran’s Affairs card. If the patient has requested that the prescription or dispense record not be uploaded to their My Health Record, you should uncheck the 'consent to send to My Health Record' flag (which can be done per line item of the prescription).
Note: Even if the patient has requested the prescription record not be uploaded, it will still go to the prescription exchange service (PES) for download by the dispenser, as per existing workflow.
Do I need my patient's consent to upload a prescription or dispense record?
There is no requirement to obtain consent each time you upload clinical information.
The My Health Record legislative framework (My Health Records Act) authorises registered healthcare provider organisations involved in a patient’s care to access and upload information to the patient’s My Health Record through the healthcare provider’s clinical software.
If the prescription or dispense record is potentially sensitive and you consider that the patient may have reservations about it being uploaded to their My Health Record, you should discuss this with the patient.
Can I edit or delete a prescription or dispense record once it has been uploaded?
The author of a prescription or dispense record can delete the record from a patient's My Health Record if it has been uploaded in error or contains a mistake.
A prescription or dispense record can be superseded, which means the author can replace the original with a new version, in case of error. However, it cannot be edited once it is uploaded to an individual’s My Health Record. A prescription or dispense record is treated the same way as other clinical documents in regards to deleting or superseding. Please refer to your software vendor for more information.