Q&A - Just tell the truth - reports, certificates and evidence

Yes you are right to provide the notes to the police if there is a valid subpoena requiring release of the notes from you. We would suggest keeping the subpoena on the patient file and advising the patient of the release.

One of the exceptions to your obligation to disclose information to the patient and to provide him or her with their records or a report that you have created in relation to them is if you reasonably believe that giving access would pose a serious threat to the life, health or safety of any individual.

There may be situations where you are concerned that providing records regarding mental health assessments etc, might pose such a threat to a patient. You may be able to redact the records, or object to providing the records on this basis.

This will be a matter for your judgement, taking into account all the circumstances.

If a patient cannot give informed consent to release of information because of their mental health – then the usual steps for obtaining consent in cases where there is impairment will apply. You may need to contact the substitute decision-maker for that person.

If you are required to disclose records and think some entries or comments should not be provided for a legitimate exception/reason, you can redact these entries. You should explain the basis for any redaction. There are limited circumstances where you can refuse to provide a patient with access to their records/a report. It can’t just be a matter of the GP preferring not to disclose the information.

If the authority is for the complete records, then you need to provide everything (subject to any privacy principle exceptions that apply). Often the request will be limited to documents about or relevant to the circumstances of the claim ie the workplace injury. If you have doubts about what you should provide, contact MIPS or the solicitors/organisation that issued the request. If you are in any doubt then do not release the records, at least without the patient’s consent.

If it appears clear that the signed consent has come from the patient then there is no need to contact them.

You are still required to be honest and not misleading. Your practice manager’s approval or disapproval is not an exception to the requirements in the Code of Conduct or any of your disclosure obligations for that matter.

We would always suggest speaking with MIPS when you’re first contacted about the inquest or a coronial investigation, and they can talk you through the specifics and let you know whether or not it’s in your best interests to be represented.

If there is a valid court order or warrant, you need to comply with this. It will override your patients objections. You should advise your patient what you have released and why. Be careful to make sure the court order/warrant relates to the documents you provide (i.e. check if the request is limited to documents after a certain date, for example).

Parents usually have authority to access their child’s medical records (and records held by the practice) because they have parental responsibility provided by the common law and the Family Act. Denying access without a valid reason may lead to a privacy complaint.

You also need to think about whether you are dealing with a mature minor and, if you are, then their wishes must be taken into account. If they are for example a mature 14 year old they may ask that the records not be disclosed and they have a right to do that. We refer you to discussion papers on Gillick competency.

Yes you can – in most jurisdictions the coroner has very broad power to compel witnesses. Often there may be witnesses who are only peripherally involved and are necessary to join 2 pieces of a factual puzzle.

We haven’t had a similar incident. But our suggestion would be to disclose information about the assault to the police that is necessary to provide the report but not to give any medical or personal information relating to the patient other than their name. You may be requested by the police to give more information at a later stage – ask for that in writing and then contact MIPS.

Ask for a subpoena before attending. If there is a subpoena – you do need to attend, even on short notice. If it’s not practically possible or inconvenient then you should contact the lawyer or court as soon as you receive the subpoena and see if another arrangement can be made.

In most jurisdictions, you are entitled to reasonable expenses for attending court sometimes referred to as ‘conduct money’. Ask the solicitor or organisation who is requesting that you attend for payment and what you are entitled to in your particular type of case and jurisdiction.

If the Coroner is requesting information under the various state and territory legislation, then separate consent is not needed and you need to comply.

Answered by MIPS: Upon the request of a member an advisor can summarise the advice given via phone, into an email and send to the member.

Records requests do extend to correspondence and reports on file. These should be disclosed. You should bear in mind the exceptions to releasing records which include if to do so may pose a serious threat to the life, health or safety of any individual. You’ll need to use your clinical judgement here. You can’t just rely on a statement included in a report or correspondence from a specialist saying that it should not be released.

If they have provided their consent, and subject to the privacy exceptions (e.g. if releasing the documents might pose a serious threat to the life, safety or health of an individual) then yes, you do need to provide everything. Most lawyers see a lot of patient files in their day to day work so will (or should) be aware of what they are requesting.

We don’t practice in Victoria so unfortunately do not have experience with TAC or the Victoria WorkCover. We expect that this might be an internal TAC requirement or statutory requirement. Give MIPS or the TAC a call if you’re unsure about your obligations in a specific case. They should be able to explain to you why and when approval is required.

There is no specific form which applies to all situations. Usually the certificate should record when the person was unwell and incapacitated for work, their name and it should be signed with your name clearly written and dated. Without this information it’s of little benefit.

The Coroner has broad powers to request documents and information relevant to a reportable death. Where the Coroner has requested documents or information, the hospital must comply with the request. To the extent that ante-mortem documents are captured by the request, they ought to be provided to the Coroner. There are exceptions to this general rule, for example where a Root Cause Analysis investigation is conducted, the RCA report must be provided to the Coroner (when requested) but documents and information forming the basis of the report need not be disclosed.

Yes it definitely can and should include what you remember, not only what’s recorded in the contemporaneous notes. It’s often useful to those reading your report to explain the basis for information in your report. For instance, you can start sentences with “I remember that during my examination of patient X…” or “on review of my notes, I understand that…”. You can also update your notes at any time. What you should do in such a case is sign or initial the change and include the date.