Recording clinical consultations

When dealing with privacy concerns in relation to health information, we often need to consider the inappropriate release of information to third parties. However, what happens when the patient requests to record the clinical consultation, or secretly records the consultation? Or the clinician records a consultation without the patient’s consent or knowledge? How should recorded health information be managed and stored, and what are the legal implications and risks for both the clinician and the patient?

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Letter from the Editor

Joanne Fitzgerald image

Welcome to Issue 1 of 2023. As communicated earlier in the year, HIM-Interchange has introduced an ‘electronic first’ publication format to support more timely publishing of articles and increase engagement with members. We hope you enjoyed the publication of a couple of electronic first articles prior to the release of this first issue for 2023. We look forward to bringing you future articles on a more frequent basis.

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Settling the injury narrative score: a health information management student and supervisor reflection

Understanding the complexities of injury relies heavily on the narrative data captured at the triage point of contact in emergency departments (ED’s). ED-based injury surveillance systems, such as the Queensland Injury Surveillance Unit (QISU), process and analyse the injury narrative data that is captured in ED systems such as the Emergency Department Information System and FirstNet in participating Queensland public hospitals. With considerations to the limitations and difficulties of capturing injury narrative data, a project was initiated by the QISU called Settling the Injury Narrative Score in 2021.

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The development of a refined classification for subacute and non-acute care: Australian National Subacute and Non-Acute Patient Classification Version 5.0

Subacute and non-acute care is currently classified using the Australian National Subacute and Non-Acute Patient (AN-SNAP) Classification Version 4 (V4), which has been used by the Independent Hospital Pricing Authority (IHPA) to price admitted subacute and non-acute care since 1 July 2016 for the purpose of activity based funding (ABF). IHPA undertakes regular review of all ABF classifications to ensure they reflect changes to patient complexity and cost over time. In 2018–19, IHPA commenced a review into the subacute and non-acute classification, resulting in the development of a refined classification.

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