Policies & Procedures

• Accessibility
• Communications
• Investigation Results
• Prescriptions
• Infection Control
• Privacy Policy
• Staff Training
• Clinical Risk
• Risk Registers

Accessibility

Patients receive the Doctor’s in-hours and after hours telephone numbers.

The Practice is conducted as a solo 24 hour practice.

All hospitals are provided with up to date contact details on an annual basis.

This is normally requested by the hospital as part of their ongoing accreditation.

The Practice policy is for urgent patients to be seen at a time to fit with the degree of urgency of their problem. This is assessed by patient request. Receptionists are very experienced but if they have doubt the doctor is consulted.

Patients are notified by phone if doctor is caused to be late by confinements.

The doctor has no regular after-hours roster, preferring to provide his own after hours cover.

However, if a locum is on duty, the various labour wards and hospitals are individually notified by the receptionist.

Communications

Patients

All patients receive a business card at the first visit. After hours recorded message advises patients of the opening hours and the after hours contact numbers.

Doctors

Referring doctors receive communication following the initial patient visit and after a procedure. Further communication is made on completion of an episode of care. Other specialists are written to as the need arises. Written patient consent is required prior to the release of copies of the medical record to any third party. All records are reviewed by the doctor prior to release.

Investigation Results

Cervical cytology reports are posted to patients on every occasion. Other results are communicated to patients at their next visit or by telephone. Abnormal report management is relayed to referring doctors after a decision is made.

Prescriptions

The policy of the Practice with respect to repeat prescriptions is that they will be provided at the discretion of the Doctor having regard to individual cases. There are no S8 drugs used in the Practice.

Infection Control

All areas of risk of infection and needle stick injury are managed by the Doctor. Receptionists are not involved in procedures or handling contaminants. Medical waste is disposed of through Medi-Waste Pty Ltd. All single use items are disposed of after use (a policy of no re-use).

Privacy Policy

The Privacy Amendment (Private Sector) Act 2000 delivers 10 National Privacy Principles.

• Collection
  Collect health information only with the consent
• Use & Disclosure
  Used within the practice, only disclosed outside practice with the patient’s consent
• Data Quality
  To be maintained with up to date information
• Data Security
  Secure from loss, misuse or unauthorised access
• Openness
  Available to patients
• Access & Correction
  Available to patients
• Identifiers
  Government identifiers only
• Anonymity
  Patients have the option
• Trans-border Data
  No information is transferred out of Australia without the patient’s consent
• Sensitive Information
  Signed consent form required

Staff Training

Prior to commencement each new employee must have orientation by a senior staff member.

Office Staff

Each 12 months a performance review is held with each employee by the practice manager.
Meetings are held monthly and all member of staff including doctors are present.

Medical Staff

All doctors follow the procedures, policies & guidelines in this Protocol. Handovers are conducted at the start and end of a locum term.

Practice Meetings – Agenda

• Issues
• Y/N
• Action
• Waiting Times
• Letters
• Bookings
• Safety
• Pathology reports
• Equipment
• Efficiency
• Sick leave
• Holidays
• Rooms repairs
• New furniture
• Other

Clinical Risk

Procedures

Sterile procedures are undertaken in a full sterile manner. Clean procedures are undertaken in a clean manner.

Cleaning up is done by the person who performed the procedure on the grounds of safety. All sharp items are disposed of correctly to a safe bin.

Stock re-ordering is done according to a stock level; this is to ensure adequate stock without excess and use by date mistakes.

Procedure Registers

• Implants – Contraceptive
• Implants – HRT
• IUCD
• IUS (Mirena)
• Colposcopy
• Cervical biopsy
• Vulval biopsy

IMPLANTS

• Type
• Insert Date
• Removal Date
• Completed
• Contacted

I.U.C.D.

• Type
• Insert Date
• Removal Date
• Follow-Up

COLPOSCOPY

• Type
• Date
• Biopsy
• Pathology
• Follow-Up

Risk Registers

Informed Consent Policy

Definition

"Informed Consent" is the process by which a patient is informed by the doctor of material risks of a procedure. In practice “Informed Consent” will arise as a result of a full discussion between patient (or guardian) and doctor with regard to indications, benefits, risks, costs, and alternatives (if any) to the particular treatment.

Purpose

The purpose of informed consent is to enable the patient(or guardian) to make an informed and voluntary decision about accepting or declining medical care based on facts and information provided to them by their doctor.

Procedure

Informed consent involves the physician informing the client of the nature of the treatment, possible alternative treatments, and the potential risks and benefits of the treatment.The person making the consent acknowledges that such disclosure of information has been made and that all questions asked about the procedure or procedures have been answered in a satisfactory manner. The informed consent form is signed by the patient or guardian if approval is given to proceed with the procedure.

Emergency Situations

If a patient is to undergo an emergency procedure, an effort should be made to have the patient or the next of kin give written informed consent (obviously depending on circumstances of the case).

If this is not practicable, progress notes to this effect must be documented by both the treating doctor and nursing staff as soon as possible after the relevant intervention documenting the nature of the emergency.

• Treatment/procedure required, and
• Steps taken in attempt to obtain consent (if any) including reasons(s) why is was not possible

Persons under 18 or not “competent”

Generally a parent or guardian is required to complete the Informed Consent to Treatment form for patients < 18 years of age. Treatment may proceed in certain circumstances without such consent if the treating doctor forms a reasonable view that the patient falls into the “mature minor” exception as recognised by the law. The Informed Consent to Treatment form will be completed by the patient in these circumstances.