NZS 8153:2002

COMMITTEE REPRESENTATION

REVIEW PERIOD

COPYRIGHT

Foreword

Contents

New Zealand Legislation

Introduction

Definition of a Health Record

Health Record – Clinical Purpose

Health Record – Non-clinical Purpose

Health Record – Additional Purpose

Scope of Application

Interpretation

Treaty of Waitangi

Health Information Privacy Code (1994)

Health and Disability Commissioner’s Code of Health and Disability Services Consumers’ Rights

1 Key Principles of Health Record Documentation

1.1 Content Accuracy

1.2 Abbreviations and Symbols

2 Health Records Content and Structure

2.1 Health Record Structure

2.2 Profession/Specialty Specific Standards

2.3 Daylight Saving

3 Consumer/Patient Details

3.1 Unique Identification of the Health Record

3.2 Individual Records

3.3 Minimum requirements of the New Zealand Health Information Service

3.4 Collecting and Verifying Consumer/Patient Identifying Information

3.5 Ethnicity Data

3.6 Consumer/Patient Nominated Contact/Representative (e.g. Next of Kin) or Agent Details

4 Key Health Information Requirements

4.1 Key Health Information Summary

4.2 Alerts/Allergies

5 Standing Orders

6 Documenting Verbal Orders and Verbal Communication

6.1 Verbal Orders

6.2 Verbal Communication

7 Appropriate Access to Health Records

7.1 Access to Health Records

7.2 Consumer/Patient Held Records

8 Research and Training

8.1 Research and Audit

8.2 Teaching, Training and Examinations

9 Health Record Compliance Audits

10 Tracking

10.1 Tracking

11 Release and Copying of Health Record Information

11.1 Release of Health Record Information

11.2 Copying/Duplication of Health Information

12 Transfer of Health Records

13 Merging and Unmerging Records Where Required

14 Safe Storage of Health Records (paper and electronic)

14.1 Filing

14.2 Storage

15 Security

15.1 Security of Electronic Health Records

16 Retrieval

16.1 Retrieval of Health Records

16.2 Transport of Health Records

17 Retention of Health Records

17.1 Retention of Health Records

APPENDIX

A Explanation of Terms

B Event Categories

C Associated Standards and Guidelines

D Power of Attorney, Enduring Power of Attorney, Welfare Guardian, Representative

E The Key Health Information Summary