NZS 8153:2002
Health records
The aim of this Standard is to inform all practitioners and service providers within public and private healthcare services, residential facilities and other relevant services of the minimum requirements for health records. Particular emphasis is placed on individual provider responsibility in relation to the maintenance of consumer/patient confidentiality, maintaining record security and preventing unauthorized use.
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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
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Related Information
Health Information Privacy Code 1994
Ministry: Privacy Commissioner
Section: Privacy breach disclosure
Citation context:Please also refer to other New Zealand Standards such as chapters 14 and 15 of NZS 8153:2002 Health Records and NZS HB 8169:2002 Health Network Code of Practice.
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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
NZS 8153:2002
Online Library subscription information
Online library subscriptions provide a cost-effective solution for organisations of any size to access the latest standards, offering 24/7 access to a personalised catalogue. The service ensures subscribers have have the most up-to-date version of selected standards, incluing automatic updates for any amendments or versions. Pricing is dependent on the chosen standards and the number of concurrent users, with discounts applied from the standards PDF price. For customised subscriptions or further inquiries, contact the Online Library team.