Accessing or updating medical records
Accessing patient or client records
People have a right to apply for access to documents held by the Child and Adolescent Health Service (CAHS). The right to apply for access is not affected by the reasons why or the health service's belief as to what the reasons are for applying. However, the reason why the documents are required may assist with identifying documents.
Access to health information may be provided by way of Administrative Release or Freedom of Information.
Administrative Release
An Administrative Release (AR) application is a less formal way of accessing information than the process prescribed by the Freedom of Information Act 1992. An AR application follows the same principals as a Freedom of Information (FOI) application, however, is not governed by the FOI Act. Under an AR release, if you are not satisfied with the decision regarding your application, there is no right to an external review by the Office of the Information Commissioner, however you are still able to request an internal review of the decision.
Freedom of Information (FOI)
The Freedom of Information (FOI) Act 1992 (PDF 355KB) gives you the right to apply for access to documents (subject to exemptions). Applications made under FOI are processed within the provisions of the FOI Act.How to request information
- be in writing (email is acceptable and preferred) or
- be lodged at CAHS (please ask at the main PCH information desk for assistance), with any application fee payable (if applicable)
- give enough information to enable the requested documents to be identified
- give an address in Australia where notices under this Act can be sent.
Lodging your application
CAHS requires your application to:- be accompanied by certified consent (photo identification) that is dated within 12 months of the request for information
- be completed on the CAHS Application for Access to Health Information form:
- Application for access to health information (Word document, 206kb)
- Application for access to health information (PDF, 133kb)
- identify which agency you are seeking information from:
- Perth Children’s Hospital (PCH)
- Community Health (CH)
- Child and Adolescent Mental Health Services (CAMHS)
- Neonatology
- identify if the information you seek is personal or non-personal
- give enough information to enable the requested documents to be identified (eg. date of attendance, service area attended and name of the document such as discharge summary)
- identify the patient clearly (e.g. full patient name including previous names or any alias’ if applicable and date of birth)
- provide details of what the request is about (optional but may assist in identifying documents).
The completed documents should be provided to:
- CAHS.ROI@health.wa.gov.au or Release of Information, Child and Adolescent Health Service, Perth Children’s Hospital, Locked Bag 2010, Nedlands WA 6909
Examples of documents held on a medical chart
A medical chart contains many documents. The following is a list of documents the ROI department would consider may be relevant to an application:
- discharge summaries
- operation reports
- imaging reports
- assessment reports
- management plan reports
- correspondence referring to care and treatment
- emergency admission sheets
General Practitioner / Specialist
Requests for access to information from your general practitioner or specialist may be made directly to the below service areas:
- Perth Children’s Hospital (PCH) - Health Information and Administrative Services (HIAS)
- Child and Adolescent Health Services - Community Health (CH)
- Child and Adolescent Mental Health Services (CAMHS)
Frequently asked questions
How can I request information for someone else?
In addition to providing a valid application, additional consent and/or supporting documentation is required when requesting information on behalf of others, or about others.- If you are requesting information on behalf of someone else, you must provide documentation which clearly shows that you are entitled to the information e.g. written consent, court orders, birth certificate, marriage certificate, death certificate.
- If you are applying for information about someone who has died, you must provide your identification, and supporting documentation that clearly shows you are the closest relative to that person e.g. birth certificate, marriage certificate or death certificate.
- If you are not the closest relative, you must provide written authorisation from the closest relative permitting you to access the information.
What information can’t be released?
Some documents fall under exemptions and cannot be released, e.g. if they compromise someone else’s privacy or commercial or business affairs. Access may be provided to an edited copy of a document if it contains information considered to be exempt.
Personal information about a third party (information about an individual other than the patient) will be deleted from the requested documents if the application is for personal information.
Can I be refused access to information?
The Release of Information (ROI) department will review your application and assist as necessary to make your application valid and identify the documents you require. If after assistance has been provided it is felt that your application is not manageable and would divert an unreasonable amount of resources from the departments other duties then access may be refused.
If an exemption applies to a document that has been requested, access can be refused.
How much does it cost?
There are no fees or charges if the application is for personal information. Applications for other documents (i.e. non-personal in nature) will incur a $30.00 application fee to be paid when the application is lodged. The following additional charges may be imposed:
- Time spent dealing with the application: $30 per hour
- Photocopying costs: 0.20c per page
- Postage and handling: cost price
You will be notified if any additional charges apply.
When will I get a decision?
Upon receipt of a valid application (correct certified consent), the ROI department allows a period of 45 days to make a decision regarding access. The release letter or notice of decision will include details such as:- the date when the decision was made
- the name and the title of the person who made the decision
- the reasons for claiming the document is exempt if access is refused
- information on the rights of review and the procedures to be followed to exercise those rights.
What happens when access is granted?
The ROI department will provide the documents via a secure health approved electronic transfer service. Alternatively, the documents can be provided to the Australian address provided on your application or you may collect copies of the documents from the ROI department located at the PCH.Please note: medical and psychiatric information may be released via a suitably qualified person nominated by an applicant and not directly to an applicant.
How do I request to have medical information changed?
If you believe your personal information held by CAHS is inaccurate, incomplete, out-of-date or misleading, you may apply to have that information amended.
To change the content of a medical record, you must provide a written request to the relevant service area providing as much detail as possible to demonstrate how or why you consider the records to be inaccurate, incomplete, out-of-date or misleading.
If you are requesting an amendment under the FOI Act you should send your written request as detailed above to the ROI department. If your request for amendment is refused you will be informed of the reasons for the decision and the process to request an internal review.
Can I apply from overseas?
The Freedom of Information Act 1992 does not apply to requests received from outside Australia.Updating patient or client details
If you need to update a patient's address and contact details or change a patient's name, please contact the relevant service directly.
To update a Perth Children's Hospital patient's name or details, visit Update patient details.