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physiotherapy.asn.au

Physiotherapists may be asked about a patient’s health information

at any time. If not handled correctly, it can have adverse

consequences for the physiotherapist and their practice.

Risk management and the prevention of claims is an important consideration for practitioners in any healthcare profession.

Insurance House supports APA members improve their practice.

Patient disclosure:

what happens when things

go wrong

CASE NOTE

Mark ran a physiotherapy practice in a small country town in

NSW. Mary had been one of his regular clients for over three

years. In 2014, Mary moved to Melbourne and requested

that her health information be transferred to a physiotherapy

practice closer to where she would be relocating. Mark

agreed to do this and proceeded to transfer her records via

email. Mark later realised that instead of transferring Mary’s

records, he had inadvertently transferred the records of one

of his other clients with the same surname.

After realising that he had transferred the wrong client’s

information, Mark agreed to have Mary’s records sent via

registered post. Because of the time it had taken, he rushed

through this at the end of the same day. Some months later,

it came to light that Mark had left out several entries relating

to his past treatment of Mary.

Mark’s errors include:

disclosing information without consent

disclosing health information without taking reasonable steps

to protect it from unauthorised access (ie, encryption)

not taking reasonable steps to ensure the health information he

was disclosing was accurate, complete and up-to-date

both Mary and the client whose information was accidentally sent

made a complaint to the health privacy regulator in their state.

Lessons for practitioners

Use and disclosure of health information

The practice should only use or disclose health information for the

primary purpose for which it was collected. Generally, the primary

purpose will be to provide quality healthcare. The practice may

use and disclose health information for directly-related secondary

purposes. For example, if a physiotherapist refers a client to a general

practitioner for necessary care, and discloses necessary parts of the

clinical history in doing so, this would be a ‘secondary purpose’.

Otherwise, the practice should only use and disclose health

information if the client gives consent (preferably express, written

consent) or if an exception applies. Exceptions include:

uses or disclosures required or authorised by the law

uses or disclosures necessary to manage a threat to

someone’s life, health or safety

uses or disclosures for research, provided certain conditions

are met.

Transfer of information to another health service provider

If care is transferred to another practice, the client should authorise

the disclosure of information from the original practice to a new

practice. The original practice needs to keep a copy of the records

as a safeguard should the patient later complain about the quality

of treatment or other matters.

A practice is required to take reasonable steps to keep personal

information, including health information, secure. This includes

during transfers. Best practice varies, but encryption of information

sent electronically is generally appropriate. Practices should check

that the recipient is capable of receiving this kind of information.

If the original practice declines to transfer a copy of the health