Organisational and legal dimensions
Organisational and legal dimensions
This domain covers the legal scaffolding of general practice: health records and privacy, certification, prescribing law, recall systems, accreditation and financial consent.
Core rules
- Records: keep clear, contemporaneous entries; correct by addendum, never by deletion. Retain adult records for at least seven years from the last entry; for a minor, until the age of 25. Records belong to the practice; patients have a right of access under privacy law.
- Privacy: the Australian Privacy Principles govern collection, use and disclosure; My Health Record access can be restricted by the patient and record-access logs are auditable.
- Certification: a Medical Certificate of Cause of Death may be issued when you know the cause and the death is expected; refer to the coroner for unexpected, violent or unexplained deaths, deaths in custody, or where cremation raises unresolved questions.
- Prescribing law: Schedule 8 medicines require state or territory authority, restrictions on quantity, and safe storage; repeats must be clinically justified.
- Fitness to drive and work capacity are statutory functions governed by Austroads-style guidelines and employment law, not patient preference.
- Accreditation against the RACGP Standards and the National Safety and Quality Primary and Community Healthcare Standards requires cold-chain monitoring, recalls and complaints systems.
Worked example
You are called to the home of a 68-year-old patient with known ischaemic heart disease found dead in bed. His wife says he seemed well last night.
Reasoning: the death is sudden and unexpected, so the coroner has jurisdiction. Do not issue a cause-of-death certificate; notify police and the coroner, provide the medical history, and support the family. Completing the certificate because “his heart was bad anyway” is unlawful.
Traps that cost marks
- Backdating or amending a record without an addendum.
- Certifying a death you cannot explain.
- Discussing an adult's care with relatives without consent.