Client Privacy and Record Keeping Policy & Procedure
Reviewed April 2023 

Policy

Newcastle Neuro Speech Pathology is committed to protecting the privacy and upholding the rights of our clients to privacy. This includes the way we collect, store and use information about our clients, their needs and the services we provide to them. Newcastle Neuro Speech Pathology is routinely required to collect and use individuals' personal and sensitive information to ensure delivery of appropriate, timely and quality services.

In line with our values, Newcastle Neuro Speech Pathology respects and upholds individuals’ rights to privacy and rights in respect of their personal information. The Privacy Act 1988 and the Health Records and Information Privacy Act 2002 (HRIP Act) govern the way in which we manage your personal information, and this policy sets out how we collect, use, disclose and otherwise manage personal information about you.

Newcastle Neuro Speech Pathology requires staff to be consistent and careful in the way they manage what is written and said about individuals and how they decide who can see or hear this information.

Newcastle Neuro Speech Pathology will ensure that:

• It meets its legal and ethical obligations as an employer and service provider in relation to protecting the privacy of clients and staff.

• Clients are provided with information about their rights regarding privacy.

• Clients and staff are provided with privacy when they are being interviewed or discussing matters of a personal or sensitive nature.

• All staff and volunteers understand what is required in meeting these obligations. This policy will apply to all records, whether hard copy or electronic, containing personal information about individuals, and to interviews or discussions of a sensitive personal nature.

Procedure

Newcastle Neuro Speech Pathology staff will:

• Ensure privacy for clients, staff and volunteers when they are being interviewed or discussing matters of a personal or sensitive nature .

• Only collect and store personal information that is necessary for the functioning of the organisation and its activities.

• Use fair and lawful ways to collect personal information.

• Collect personal information only by consent from an individual.

• Ensure that people know what sort of personal information is held, what purposes it is held for and how it is collected, used, disclosed and who will have access to it.

• Ensure that personal information collected or disclosed is accurate, complete and up-to-date, and provide access to any individual to review information or correct wrong information about themselves.

• Take reasonable steps to protect all personal information from misuse and loss and from unauthorised access, modification or disclosure.

• Destroy or permanently de-identify personal information no longer needed and/or after legal requirements for retaining documents have expired.

Responsibilities for managing privacy:

•  All staff are responsible for the management of personal information to which they have access.

• The Directors are responsible for content in Newcastle Neuro Speech Pathology’s publications, communications and website that represent the company, and must ensure the following:

• Appropriate consent is obtained for the inclusion of any personal information about any individual including Newcastle Neuro Speech Pathology staff.

• Information being provided by other agencies or external individuals conforms to privacy principles − that the website contains a Privacy statement that makes clear the conditions of any collection of personal information from the public through their visit to the website.

• The Directors are ultimately responsible for ensuring that the personal information of individual clients acrossNewcastle Neuro Speech Pathology is safeguarded appropriately, and that all client records are maintained in accordance with all relevant standards, principles and legislation.

Privacy information for clients

At the initial appointment with Newcastle Neuro Speech Pathology, prospective clients will be told what information is required to be collected, how their privacy will be protected and their rights in relation to this information. This will be signed as a Service Agreement or Client Consent form.

Collecting identifiable data

Newcastle Neuro Speech Pathology collects and records the following information about individual clients:

• General demographics - name, address, gender, age, next of kin, contact details, and advocate details where appropriate.

• Service delivery details - GP and other service agencies involved in care, client goals, current plan of care determined with client, client consent to share information and enable service delivery, signed client service agreement, other information relevant to ongoing care.

• Physical environment health & safety information – home safety checklist, risk management plans (where relevant).

This information is collected for the purpose of:

• Developing an accurate client record and client file

• Monitoring and management of services to individuals

• Service evaluation and reporting (de-identified information only is used for this purpose)

The staff member will ask the client if they have any concerns or specific requests about the way their personal information will be recorded or managed. If identifiable information about a client will be shared with another agency, the staff member will obtain the client’s consent for this and record the date of the verbal consent/obtain the client’s signature on a consent form.

Storage and Use of Information / Data Security

Newcastle Neuro Speech Pathology strives to ensure the security, integrity, and privacy of client personal information. Periodically we review and update our security measures in relation to current and future technologies. Systems and procedures are already in place to protect personal information from interference, misuse and loss and from unauthorised access, modification or disclosure, including electronic and physical security measures. Newcastle Neuro Speech Pathology will retain information in line with relevant laws. When information is no longer required or relevant it will be de-identified or destroyed in accordance with relevant laws.

Storage and use of identifiable data Information collected about individual clients is stored in the following ways:

• The Newcastle Neuro Speech Pathology electronic client document management system, “Splose” stores client information to a cloud-based system.

• All personal client information and care details are contained within their client file in Splose.

• Access to Splose is password protected as per the Newcastle Neuro Speech Pathology Information Technology Policy and Procedures.

• Access to the client’s file is based upon permissions being given by the Director. The permissions are granted to relevant clinicians and other staff members.

• All word documents are saved on the g-drive in the client’s report folder. Access to the g-drive is password protected as per the Newcastle Neuro Speech Pathology Information Technology Policy and Procedures.

• On occasion, when it is necessary to carry client records/documents in the community, records are transported securely on the person of the clinician. After the appointment, the clinician scans the paper record to the cloud-based case management software and stores it securely or shreds the documents.

• The relevant staff members are responsible for ensuring and managing the filing of client records in the Splose system.

• Client records will be updated against need for all clients.

• Newcastle Neuro Speech Pathology files are updated regularly during the period of an active file.

• Refer to the Closing Files Procedure on how files are closed.

Client Access

Clients may access the personal information Newcastle Neuro Speech Pathology holds about them, upon making a written request. Newcastle Neuro Speech Pathology will respond to your request within a reasonable period. We may charge you a reasonable fee for processing your request (but not for making the request for access).

We may decline a request for access to personal information in circumstances prescribed by the Privacy Act, and if we do, we will give the client a written notice that sets out the reasons for the refusal (unless it would be unreasonable to provide those reasons).

If, upon receiving access to personal information or at any other time, if the client believes the personal information, we hold is inaccurate, incomplete or out of date, they can notify us at any time. Newcastle Neuro Speech Pathology will take reasonable steps to correct the information so that it is accurate, complete and up to date.

If Newcastle Neuro Speech Pathology refuses to correct personal information, we will give written notice to the client that sets out our reasons for our refusal (unless it would be unreasonable to provide those reasons), including details of the mechanisms available to you to make a complaint.

• The request will be directed to the Director that a client wishes to access their file.

• The Director will then negotiate directly with the client or their guardian/advocate how best to facilitate access.