Clinical documents support the continuity of care, and improve the interactions between healthcare providers and patients.
When is it appropriate to upload clinical information to a My Health Record?
How and when you upload should be guided by your need for information to support your clinical decision-making. Similarly, the information you choose to upload to the My Health Record system should be guided by whether that information will be of benefit to other healthcare providers, and therefore the individual, in the future.
In accessing an individual’s My Health Record you should remain mindful that it may not include a record of every interaction they have had with the health system or an up-to-date status of their health. You should continue to verify the information in the individual’s My Health Record with them and where necessary, other healthcare providers.
While you are not obliged to use the My Health Record system with every individual or for every encounter, it is important to be able to recognise those instances when it will be particularly beneficial.
For further details, see: Understand when you can view and upload information
How do I upload clinical information to a My Health Record with clinical software?
Each software has its own 'look and feel' for how it displays information in an individual’s My Health Record, but the actual documents themselves are the same regardless of the software used. Similarly, each software has its own process for uploading information.
There are clinical software simulators in which you can simulate viewing and uploading to a fictional patient’s My Health Record through some common software types. There are also software simulators and demonstrations with step-by-step instructions for viewing and uploading with various software products (see below).
If your software is not listed below, contact your software vendor for information about how to view and upload with your software.
Note: Live My Health Records must not be used for practicing or experimenting with the My Health Record system.
Clinical software simulators
There are a range of clinical software simulators or ‘sandboxes’ with which you can simulate viewing, creating and uploading clinical information to fictional patients’ My Health Records, as well as carrying out Assisted Registration. The software simulators include: Bp Premier, MedicalDirector, Zedmed, Genie, and Communicare.
Clinical software demonstrations
There is a range of slideshows showing how access and upload to My Health Record in some clinical software products.
Clinical software summary sheets
There are summary sheets for a range of clinical software products with step-by-step instructions and screenshots. Access these here.