Healthcare providers like doctors, pathologists, and pharmacists can add clinical documents to your record.
A clinical document contains information about your health and care. There are a wide range of clinical documents that can be added.
These can include:
- Your shared health summary – an important summary of your health, usually added by your GP. It can include conditions you have been diagnosed with and medications you take. It can also contain allergies and adverse reactions that other healthcare providers need to know about and details of any vaccinations given.
- Hospital discharge summaries – information about your stay during a visit to hospital.
- Event summaries – these are created when you have an important health event. For example, starting or finishing a treatment, seeing an improvement in a health condition, details of any vaccinations given, or a procedure that is relevant to your future care.
- Specialist letters – a letter that a specialist who is treating you writes to your GP. Specialist letters provide GPs with information and recommendations that are relevant to your ongoing care like diagnoses, medication changes, and treatment plans.
- Referrals – these are usually created when a GP refers you to a specialist. Referrals include information the specialist needs to know, like why you were referred, your medications, test results, allergies/adverse reactions, and your medical history.
- Test results – including pathology reports (e.g. from a blood test or a biopsy) or diagnostic imaging reports (e.g. from an x-ray or MRI).
Who can view clinical documents?
Once a clinical document has been uploaded to your record, it can be viewed by you and:
- Doctors and other healthcare providers who are involved in your care
- People you have invited to access your record (also called nominated representatives)
- People who have legal permission to access your record if you lack the capacity to manage it yourself (also called an authorised representative)
You can control who can see your information by adjusting your privacy settings.
