<<Insert Practice Name>>
Policy & Procedure Manual
<<Date of Creation>>
<<Date of Review>>
1
Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Disclaimer
This manual has been developed to assist practices with the policies and procedures required
for accreditation and the day-to-day management of a general practice.
This manual has been developed by IWSML based on the V11 July 2011 template published
by Quality in Practice (QIP)/AGPAL and written by Dandenong Casey General Practice
Association (DCGPA). CSGPN would like to acknowledge the work completed by DCGPA
and the members of their accreditation advisory committee in putting this manual together.
This manual has been designed to comply with the RACGP 4th Edition Standards for General
Practice.
It is intended to be a generic manual only. It must be adapted and changed to reflect the
current situation within your practice.
Please amend or delete policies and procedures as required however be mindful that deletion
of some policies and procedures may jeopardize your compliance with the RACGP Standards
and therefore your accreditation status.
Always refer to the RACGP 4th Edition Standards and relevant State and Federal legislation
when amending the manual template.
IWSML does not accept any liability for loss, injury or damage incurred or reliance on the
information contained within. The practice has a responsibility to ensure that it meets it’s
State and Federal legal obligations as a general practice.
Instructions
This manual has been developed with best practice guidelines to develop a generic template
for wide spread use. Due to the vast differences between general practices in Australia, you
are required to amend the policies and procedures according to your own practice situation
including staff, equipment and methodology.
Sections highlighted in BLUE represent areas where practice-specific information must be
entered. It is recommended that all sections, even those not highlighted, be reviewed to ensure
they are accurate and correct.
It is suggested that once all sections have been amended, that you remove the highlighted
sections and symbols for customization.
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Table of Contents
1
Introduction ................................................................................................. 6
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Mission Statement ........................................................................................................ 6
Practice background .................................................................................................... 6
Practice profile .............................................................................................................. 6
Practice team................................................................................................................. 7
Practice services .......................................................................................................... 8
Practice hours ............................................................................................................... 8
Practice consultation fees ........................................................................................... 9
2
Human Resources ..................................................................................... 10
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
Awards & Entitlements............................................................................................... 10
Staff Recruitment ........................................................................................................ 11
Position Descriptions ................................................................................................. 12
Staff Employment Records ........................................................................................ 13
Staff Induction ............................................................................................................. 15
Privacy ......................................................................................................................... 17
Performance Review .................................................................................................. 18
Staff Code of Conduct ................................................................................................ 20
Equal Opportunity, Bullying & Harassment ............................................................ 21
Anti-discrimination policy ......................................................................................... 22
3
Occupational Health & Safety .................................................................. 25
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Manual Handling ......................................................................................................... 29
Incidents and Injury and Adverse Patient Events ................................................... 31
Sharps Injury Management and Other Body Fluid Exposure ................................ 33
Staff Immunisation ..................................................................................................... 35
Smoke-Free Environment .......................................................................................... 37
Staff Health and Wellbeing (including GPs) ............................................................ 37
Practice Facilities ....................................................................................................... 38
Security ........................................................................................................................ 39
Non Medical Emergencies ......................................................................................... 40
4 Infection Control ............................................................................................... 42
4.1
4.2
4.3
4.4
4.5
4.6
Principles of infection control ................................................................................... 42
Blood and body fluid spills ........................................................................................ 44
Hand washing and hand hygiene.............................................................................. 47
Single Use Equipment ................................................................................................ 50
Offsite Sterilisation ..................................................................................................... 51
Onsite Sterilisation ..................................................................................................... 55
4.7.1
Instrument and equipment processing area ..................................................................................... 57
4.7.2
Cleaning reusable Instruments and equipment ............................................................................... 60
4.7.3 Loading the steriliser ............................................................................................................................ 64
4.7.4 Unloading the steriliser ........................................................................................................................ 66
4.7.5 Documentation of the Cycle ................................................................................................................ 68
4.7.6 Monitoring the Sterilisation Process .................................................................................................... 69
4.7.7
Validation of the sterilisation processes ........................................................................................ 70
4.7.8
Maintenance of the steriliser .......................................................................................................... 74
4.7.9
Servicing the steriliser .................................................................................................................... 74
4.9
4.10
Storage of sterile items .............................................................................................. 75
Management of waste ................................................................................................ 76
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Adapted by IWSML based on work produced by Dandenong Casey General
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4.11
Sharps Management.............................................................................................. 78
4.12
Transmissible and Notifiable Diseases ................................................................... 80
4.13
Standard Precautions................................................................................................. 82
4.14 Additional Precautions.................................................................................................. 83
4.15
Personal Protective Equipment (PPE)...................................................................... 84
4.16
Laundry ........................................................................................................................ 87
4.17
Safe handling of pathology specimens.................................................................. 89
4.18
Environmental Cleaning Service .............................................................................. 89
5
Practice Management ............................................................................... 94
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
Access & Parking ....................................................................................................... 94
Appointments .............................................................................................................. 95
Home Visits ............................................................................................................... 100
Telephone .................................................................................................................. 102
Electronic Communication ...................................................................................... 104
Medical Emergencies & Urgent Queries ................................................................ 105
After Hours Service .................................................................................................. 107
Practice Meetings ..................................................................................................... 108
Patient Rights ............................................................................................................ 111
Complaints ................................................................................................................ 112
Non English Speaking Patients............................................................................... 115
5.11.1 Culturally Appropriate Care ............................................................................................................ 116
5.12
5.13
5.14
5.15
Directory of Local Health and Community Services............................................. 117
Provision of Brochures, Leaflets and Pamphlets for Patients ............................ 118
Practice Information Sheet ...................................................................................... 120
Office Supplies .......................................................................................................... 122
6
Privacy and Personal Health Information ............................................. 123
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
Privacy and Security of Personal Health Information .......................................... 123
Computer Information Security............................................................................... 125
Practice Privacy Policy ............................................................................................ 127
3rd Party Requests for Access to Medical Records/Health Information ............. 129
Request for Access to Personal Health Information ............................................ 131
Medical Records Administration Systems............................................................. 133
Retention of Records and Archiving ...................................................................... 135
Transfer of Medical Records ................................................................................... 136
7
Clinical Management .............................................................................. 138
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
Clinical Autonomy .................................................................................................... 138
Clinical Content of Medical Records ...................................................................... 139
Informed Consent ..................................................................................................... 141
Referral Protocols.................................................................................................... 142
Clinical Handover ..................................................................................................... 144
Follow up of Tests, Results and Referrals ............................................................. 146
Reminder Systems for Preventative Care .............................................................. 148
3rd Party Observing or Clinically involved in the Consultation .......................... 149
Practice Participation in Research Projects .......................................................... 150
Management of a Patient Refusing Treatment or Advice .................................... 151
Refusal to Treat a Patient ........................................................................................ 152
Practice Equipment .................................................................................................. 153
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7.13
Doctor’s Bag.............................................................................................................. 155
7.14
Vaccine Storage ....................................................................................................... 156
7.15 Medication Prescribing and Administration ............................................................... 157
7.16
Controlled Substances............................................................................................. 159
7.17 Clinical References and Resources............................................................................. 161
7.18
Drug Storage and Disposal .................................................................................... 162
8 Continuous Improvement .............................................................................. 164
8.1 Risk Assessment & Management .................................................................................. 164
8.2
Review of Policies & Procedures ............................................................................ 166
8.3 Continuing Staff Education ............................................................................................ 167
8.4
Accreditation & Continuous Improvement ............................................................ 170
8.5
Patient Feedback ...................................................................................................... 171
8.6
Continuity of Care..................................................................................................... 173
8.7
Clinical Governance ................................................................................................. 174
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Adapted by IWSML based on work produced by Dandenong Casey General
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1
Introduction
1.1
Mission Statement
Option 1: Use the sample practice mission statement below
Our mission is to provide the highest standard of patient care whilst incorporating a
holistic approach toward diagnosis and management of illness.
We are committed to promoting health, wellbeing and disease prevention to all
patients. We do not discriminate in the provision of excellent care and aim to treat all
patients with dignity and respect.
Option 2: Add your own practice mission statement here
1.2
Practice background
Write a short description of your practice here. Areas you may wish to include are
the history behind your practice, location, particular interest areas, communities the
practice services and other important information you would like to add.
1.3
Practice profile
Name of practice
* name of practice
Street address
* street address
Postal address
* postal address
In hours phone number
*in hours phone number
After hours phone number
* after hours phone number
Fax number
* fax number
Email address
* email address
Web address
* web address
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
1.4
Practice team
Medical
* Medical position
* name of medical person
* Medical position
* name of medical person
* Medical position
* name of medical person
* Medical position
* name of medical person
* Medical position
* name of medical person
Allied health
* Allied health professional
* name of allied health professional
* Allied health professional
* name of allied health professional
Nursing
* Nursing position
* name of nurse
* Nursing position
* name of nurse
Administrative
* Administrative position
* name of administrative person
* Administrative position
* name of administrative person
* Administrative position
* name of administrative person
* Administrative position
* name of administrative person
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
1.5
Practice services
In addition to general medical consultations, our practice offers the following services:
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
* insert practice services
(Customise as appropriate)
There is a range of posters, leaflets, and brochures about health issues relevant to the
community available for all of our patients in:

the waiting room

the consultation rooms.

1.6
Practice hours
Monday to Friday
* Monday to Friday hours
Saturday
* Saturday hours
Sunday
Home visits
* Sunday hours
* Regular hours that home visits are conducted
Home visit appointments can be made outside these times by
prior arrangement with the receptionist at the discretion of
the doctor.
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
1.7
Practice consultation fees
(Customise as appropriate)
<<A schedule of our fees is listed below>> OR <<All services performed at this practice are
bulk-billed>>
An up-to-date copy of our schedule of fees is located:

at reception

in the practice information sheet.
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Adapted by IWSML based on work produced by Dandenong Casey General
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2
Human Resources
Research from both general practice and other industries supports the importance of attention
to human resources. Good human resource management supports good clinical care (RACGP
4th Edition Standards 2010).
2.1
Awards & Entitlements
(Customise as appropriate)
Policy
This practice complies with all its legal obligations under the Fair Work Act 2009 with
regard to employees. These include:
 provision of rates of pay, leave and other entitlements as set out in the relevant
Award or workplace agreement;
 a safe and healthy workplace;
 equal opportunity and freedom from discrimination and harassment
 protection of employee and patient privacy; and
 maintenance of appropriate staff records
 compliance with the National Employment Standards
Additionally, this practice follows established procedures and policies for employment
and management of staff, including:
 clear communication of expectations and standards, using position descriptions and
job specifications as well as staff codes for conduct and presentation.
 recruitment procedures which are fair, thorough and facilitate selection of the best
candidate.
 a formal induction procedure for all staff, to familiarise them with important
practice procedures relating to patient care, occupational health and safety,
emergencies, confidentiality and conduct.
 regular feedback and opportunities for development through performance review.
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Adapted by IWSML based on work produced by Dandenong Casey General
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Procedure
In our practice, all staff members have a signed employment contract which complies
with their relevant Modern award and the National Employment Standards (NES).
Records of staff contracts can be found <<insert location of staff contract records>>.
The Modern awards used by this practice to employ staff are as follow: <<customise as
appropriate>>
 Health Professionals and Support Services Award 2010
 Nurses Award 2010
 Medical Practitioners Award 2010
Our practice has obtained advice to ensure that all employee contracts comply with the
relevant legislation.
RACGP 4th edition Standards 4.1.1.
2.2
Staff Recruitment
(Customise as appropriate)
Policy
Effective selection and management of staff is critical to the success of this practice. Our
ability to care for patients and operate a successful medical practice depends upon attracting,
developing and retaining the right people.
Before the recruitment process begins, our practice analyses the position requirements by
asking the following questions:






What are the most important tasks this position will be carrying out?
Are there any additional tasks that they could be doing?
What knowledge, skills, qualifications are required to perform the role?
Are there any particular attributes which are necessary for the role?
Who will the position report to and who is responsible for this supervision?
Will the position be full-time or part-time and how will it be renumerated?
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
Can these tasks not already be performed by current staff?
Once these questions have been answered, the information is used to develop the following
documents:
 Position description
 Job vacancy advertisement
 Performance appraisal outline
 Selection criteria
Procedure
The recruitment process of our practice is thorough and conducted in a way that is fair and
complies with relevant legislation.
Once a suitable candidate has been selected, the applicant is notified in writing and supplied
with copies of:
 The employment contracts
 Position description
 Confidentiality agreement
 Personal details form
 Tax file declaration form
 Super Choice form
 Banking details form
 Current immunisation status declaration form
 Information about recommended vaccinations
It is the responsibility of <<insert person responsible>> to coordinate and carry out all the
practice recruitment functions. When required, this person will consult other relevant
members of the practice.
2.3
Position Descriptions
(Customise as appropriate)
Policy
General practitioners and other staff need documented position descriptions that outline and
define their current roles, responsibilities and conditions of employment.
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Adapted by IWSML based on work produced by Dandenong Casey General
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Position descriptions are signed by employees to indicate that roles and responsibilities are
acknowledged and understood.
Included within our position descriptions are any designated areas of responsibility. All
members of the practice team are able to identify the person(s) who have designated
responsibility in the following areas:








Cleaning
Complaints management
Quality Improvement
Infection Control
Information technology
Risk management systems
Sterilisation
Vaccine management
Procedure
The position description outlines:
 Key selection criteria, skills, qualifications, etc. required for the role
 Duties, responsibilities and hazards associated with the position
 Remuneration and entitlements
 Timetable for annual performance reviews
Position descriptions are reviewed regularly during performance appraisals or on a needs
basis whenever a member of the team leaves the practice.
RACGP 4th edition Standards 4.1.1, 5.3.2, 5.3.3, 4.2.2
2.4
Staff Employment Records
(Customise as appropriate)
Policy
A range of information must be made and kept for each employee as prescribed by the Fair
Work Act 2009 and Fair Work Regulations 2009. Our practice understands that penalties
apply to employers who fail to comply with the record-keeping requirements of the Fair Work
Act 2009.
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Therefore we maintain staff employment records which comply with all legal and
statutory obligations.
The following information is kept as part of the mandatory employment records of all
staff working in this practice:









Details of the employer including ABN, employee commencement date and basis
of employment (ie. Full-time, part-time.)
Pay records including the rate of pay, gross and net amounts, and details of
financial incentives
Hours of work including any overtime
Leave records
Superannuation contribution records
Individual flexibility arrangements (if applicable)
Guarantee of annual earnings record (if applicable)
Termination records
Transfer of business records
All clinical staff including GPs must be able to provide evidence of appropriate national
registration and evidence of satisfactory participations in prescribed professional
development activities in accordance with their relevant vocation.
All staff must have undertaken CPR training in accordance with the Australian
Resuscitation Council very 3 years.
Procedure
Our employee records are:







in a form that is readily accessible to a Fair Work Inspector
legible and in English (preferably in plain, simple English)
kept for seven years
not altered unless for the purposes of correcting an error
not false or misleading to the employer’s knowledge.
private and confidential. Generally, no one can access them other than the employee,
their employer, and relevant payroll staff.
made available at the request of an employee or former employee(copy only).
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Evidence of staff qualifications are kept as part of the staff employment records. Copies
of national registration and current CPR training can be found <<insert location that
records are kept>>.
RACGP 4th edition Standards 3.2.1, 3.2.2 & 3.2.3 & 4.1.1.
2.5
Staff Induction
(Customise as appropriate)
Policy
Practices need a system for assisting new members of the practice team to learn their role.
This includes new GPs, registrars and locums, and other new staff.
Our practice has an induction program for all new General Practitioners and practice staff
which includes ongoing monitoring of progress in their new role. To ensure staff and patient
safety, new members of the general practice team must be able to demonstrate knowledge of
the key procedures in the Policy and Procedure Manual and key operating systems relevant to
their role within the practice by the end of the induction period. Where appropriate, we have
provided other contractors using rooms in the facility with an overview of relevant practice
systems.
Staff are also expected to familiarise themselves with the Policy and Procedure Manual and
use it as a resource in the course of their employment.
All new staff must complete a full induction program including Workplace Health and Safety
(WH&S) as detailed on the Staff Induction Checklist as part of their orientation.
It is essential that new staff understand the day-to-day operations of the practice including the
occupational health and safety issues relevant to their role, the practice code of conduct,
infection control policies and the processes by which the privacy of patient health
information.
It is useful for new staff to have an understanding of the local health and cultural environment
in which the practice operates. Furthermore, staff and GPs in particular need to be aware of
key public health regulations (such as reporting requirements for communicable diseases or
mandatory reporting of child abuse) that will affect how they work. General practitioners need
to be made aware of local health and community services including pathology, hospital and
other services they are likely to refer to in the course of normal consulting.
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The Staff Induction Checklist provides the general knowledge essential for any position
within a medical practice. Job specific orientation and induction will also need to be
undertaken and documented.
As each stage of the induction program is completed with the new staff member and their
induction supervisor sign the Staff Induction Checklist and the completed document is filed in
the employee’s Staff Record file. This written record of induction is important to protect the
practice against legal liability and injury claims in the future.
New staff members are not permitted to work independently until competency in specific
areas of induction such as infection control, confidentiality and WHS have been demonstrated
and signed-off.
Procedure
The following overview and checklist can be customised to reflect the practice’s needs.
Process
Before the first
day.
First day
First week

Description
Appoint a member of staff to be responsible for the new employee
induction.
Prepare Staff Induction Checklist and have copy of procedures
manual & job description available to refer to.
Make the new staff member feel welcome.
Go through all items on the Staff Induction Checklist
Prepare Staff Induction Checklist - Induction &Training Plan
Sign the Staff Induction Checklist Part 1 - First Day to show all
items have been completed
File Staff Induction Checklist Part 1 - First Day and a copy of Part 2
- Induction &Training Plan in the new employee’s staff records file.
Give a copy of all induction forms including Staff induction
Checklist -Key policies and procedures to the employee.
Make time each day to go through key policies, procedures and
other training needs identified on the Induction &Training Plan
Arrange induction and training with other staff members in areas
such as reception systems, record-keeping, sterilisation/infection
control & spills, doctor’s requirements, customer service and
complaints, patient privacy, triage.
Provide opportunities for the new staff member to ask questions,
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First month
After 3 months
and make sure they receive plenty of feedback and encouragement.
Tick off each item on the Induction &Training Plan as it is
completed.
Continue to provide the new employee with opportunities to ask
questions as well as encouragement and support with regular
informal meetings.
Link the new staff member into local networks and professional
organisations, such as those at the division.
Continue Induction &Training Plan until all items are completed.
Sign the Induction &Training Plan to show it has been completed.
Give a copy to the employee and file the original in the employee’s
Staff Records File.
Review the induction and training plan and their performance.
Provide recognition for the areas which they are performing well in
and develop a new plan to resolve any remaining training needs or
provide skills enhancement – Performance Review.
All completed staff induction records are kept <<insert location of induction records>>.
RACGP 4th edition Standards 4.1.1
2.6
Privacy
(Customise as appropriate)
Policy
All patient information is private and confidentiality of patient information must be
maintained at all times. The rights of every patient are to be respected. All information
collected by this practice in providing a health service is deemed to be private and
confidential.
This practice complies with Federal and State privacy regulations including the Privacy
Act 1998 and the Privacy Amendment (Private Sector) Act 2000, as well as the standards
set out in the RACGP Handbook for the Management of Health Information in Private
Medical Practice 1st Edition (2002).
Under no circumstances are employees of this practice to discuss or in any way reveal
patient conditions or documentation to unauthorised staff, colleagues, other patients,
family or friends, whether at the practice or outside it, such as in the home or at social
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occasions. This includes patient’s accounts, referral letters or other clinical
documentation.
General Practitioners and staff are aware of confidentiality requirements for all patient
encounters and recognise that significant breaches of confidentiality may provide grounds
for disciplinary action or dismissal.
Every employee of this practice is aware of the privacy policy and has signed
confidentiality agreement as part of their terms and conditions of employment. This
confidentiality agreement continues to be binding on employees even after their
employment has terminated.
Procedure
All employees of this practice are issued with the privacy policy and sign a
confidentiality agreement as part of their terms and conditions of employment. The
policies and procedures of the practice are further explained during the induction of new
staff members, and the induction form is signed by the new employee as confirmation
that they understand and accept their obligations in relation to patient privacy and the
confidentiality of medical information.
Copies of signed staff confidentiality agreements are kept <<insert location of
confidentiality agreements>>.
RACGP 4th edition Standards 4.2.1 & 4.2.2
2.7
Performance Review
(Customise as appropriate)
Policy
Annual staff reviews are conducted to ensure continuing high levels of work performance and
to assist in job enrichment. The review is part of a continuous process of feedback to
individual staff on their work performance. It is extended to include performance
improvement and career development.
Performance reviews benefit the practice and its employees by:
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




ensuring all staff know what is expected of them and how their work is important to the
practice.
providing staff with formal recognition and appreciation for their work.
providing an opportunity to review goals, celebrate achievements and set objectives for
the future.
helping staff to develop their skills and performance to achieve practice goals and
further their own career.
dealing with problems and resolving grievances – see also Grievance Procedure in 2.10
Equal Opportunity, Bullying and Harassment.
A review involves identifying, evaluating and developing the work performance of staff so
that Practice goals are more effectively achieved. At the same time the process benefits staff
in terms of recognition, receiving feedback, catering for work needs and offering career
guidance and support.
The relevant position description forms the basis for evaluation and lines of accountability.
The performance review document, including comments concerning current progress and
future goals, is signed by both parties, with a copy retained by the staff member. The original
is filed in the Staff Record File.
Procedure
A review is conducted 3 months after commencement of the position and at least annually
thereafter. Depending on the staff member, reviews may occur more frequently as required.
The employee to be reviewed is issued with a self-appraisal template and a copy of their
current position description at least 1 week before their review meeting.
Review meetings are conducted where both parties are able to discuss their views on the
position and set goals for the next 12 months. A training plan and goal sheet is completed
with a copy provided to the employee and a copy incorporated in the staff members records.
Any amendments that need to be made to the position description are updated and a new copy
filed in the staff record as well as being provided to the employee.
RACGP 4th edition Standards 4.1.1.
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2.8
Staff Code of Conduct
(Customise as appropriate)
Whilst this procedure is advised, there is no longer the requirement of three warnings.
However, the employee must be given ‘a fair go’ and have an opportunity to improve within a
reasonable time frame. Always document these issues.
Policy
We encourage an environment that fosters robust general practice teams.
Our staff conduct themselves in a manner that promotes the attributes we believe are desirable
characteristics of general practice team:






a just, supportive, transparent, cohesive and collaborative culture, which is associated
with improved patient outcomes and enhanced patient safety.
defined goals, including an identifiable overall practice ‘mission’ and specific,
measurable operational objectives that are shared by all team members.
a ‘systems’ approach that includes the development of both clinical systems and
administrative systems.
division of labour, including the delegation of tasks and assignment of tasks among
team members.
effective training, both for the functions that people routinely perform and cross
training to substitute for other roles in cases of absences or changed/increased work
demands.
excellent communication, including supportive interpersonal communication through
well designed communication structures and processes.
All staff are issued with an employee code of conduct when commencing employment.
A copy of the code of conduct can be found <<insert location where code of conduct can be
viewed>>.
All breaches of the code will be investigated by the employee’s supervisor in a professional
manner.
Counselling and disciplinary action of employees will take place and be documented in
<<insert method of documentation>> for any breaches of this code of conduct. Employees
are aware that gross breaches of the code may result in dismissal from the business.
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<<Insert person responsible>> is responsible for ensuring that all staff comply with the
practice code of conduct and to deal with any breaches in a professional and fair manner.
RACGP 4th edition Standards 4.1.1
2.9 Equal Opportunity, Bullying & Harassment
(Customise as appropriate)
Policy
Our practice is committed to the principles of merit, fairness and respect for all people. This
practice seeks to provide a working environment in which all employees are able to perform
their duties without being subject to discrimination or inappropriate behaviour. Our practice
complies with our legal obligations and has a range of policies and procedures to encourage
Equal Opportunity and prevent discrimination, bullying and harassment. These include:



a policy preventing bullying and harassment of any kind, including sexual
harassment, in this workplace.
a procedure to deal with the personal threat of violence
a grievance procedure for complaints arising from breaches of these policies. For
serious breaches the practice’s disciplinary procedures may be used, including
termination of employment.
All staff working at this practice have the responsibility to:
 treat all people in this workplace fairly and with respect.
 refrain from behaviour which could constitute harassment, bullying or
discrimination
 report any incidents of harassment, bullying or discrimination to the designated
complaints person
 maintain confidentiality if they are involved in complaints.
Bullying and Harassment Policy
There are a number of laws in Australia dealing with issues related to bullying and
harassment including EEO legislation, OHS requirements, criminal law, defamation and
common law provisions such as negligence. These laws all require the employer to take all
reasonable steps to stop bullying and harassment in the workplace, including:
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1) Policies and procedures to prevent bullying and harassment
2) Dealing with grievances in a fair, appropriate and timely manner.
Bullying and harassment is defined as any unwelcome behaviour or communication which
has no legitimate function in the workplace and intimidates, humiliates or offends another
person. Any form of bullying or harassment is totally unacceptable in this practice.
<<Insert Practice Name>> regards these actions and any similar behaviour as serious
misconduct and any person who is found to be behaving in this manner may have their
employment terminated.
Any employee who is subjected to bullying, harassment or intimidation by a fellow employee,
manager or supervisor should notify the designated complaints person. All complaints of
harassment will be promptly and confidentially investigated using the practice’s grievance
procedure. Any employee or manager who violates this policy will be subjected to
disciplinary action, as described above.
2.10 Anti-discrimination policy
This practice does not discriminate on the basis of:
 race (including colour, nationality and ethnic origin).
 family status including marital status and responsibilities as a carer.
 sexual orientation and lawful sexual activity.
 age.
 gender and gender identity.
 physical Features.
 political beliefs or activity.
 religious beliefs or activity.
 breastfeeding.
 impairment including physical, intellectual or psychiatric.
 pregnancy or potential pregnancy.
 political opinion or activity.
 criminal record.
 union membership or industrial activity.
 personal association with a person with any of the above characteristics.
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Adapted by IWSML based on work produced by Dandenong Casey General
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Grievance Procedure
If you or any employee of this practice is exposed to any form of behaviour which constitutes
discrimination, bullying or harassment, the following procedure must be adopted.Do not
ignore harassment – ignoring the behaviour could be interpreted as consent.
This procedure may also be used for handling of other workplace grievances such as
complaints about working conditions, wages or work colleagues. Grievances undermine
morale and affect teamwork and need to be dealt with promptly.
1) Inform the offender that the behaviour is offensive and unacceptable.
2) Seek assistance in having the behaviour stopped by reporting the incident to your
designated complaints person
3) The investigator/designated complaints person will conduct a detailed investigation of
the incident(s) to assist in the resolution of the grievance. Witness statements and
evidence may be collected. For the investigation to be properly conducted
confidentiality must be maintained, it must be impartial, the person reporting the
incident must not be victimised or experience adverse repercussions and the complaint
must be dealt with as quickly as possible.
4) Actions taken to resolve the grievance will depend on the circumstances and the results
of the investigation. Generally the main aim will be to ensure the incident does not
occur again. Possible solutions may include:
 an apology.
 an undertaking that the behaviour will cease.
 formal counselling of the alleged harasser, using the disciplinary procedure (2.7)
 disciplinary action, including termination for serious misconduct.
 training for groups of staff or the whole staff to raise awareness of EEO
obligations.
 covering costs associated with the harassment, such as medical or psychology
expenses.
 notifying the police.
 if the complaint cannot be substantiated when it is investigated it must still be
taken seriously, including attempting to find a resolution of the mater with the
employees involved.
 it may be appropriate to take action against a complainant who makes a serious
allegation against a work colleague which is found to be false or frivolous after
investigation. This could include termination of employment.
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5) A record is kept of the complaint, its investigation and actions taken.
6) After action has been taken and the problem appears to have been resolved there is a
need for occasional monitoring and follow-up to ensure that those involved are satisfied
with the outcome, and the problem has not reoccurred or surfaced in a different form.
7) If the matter remains unresolved, the grievance provisions in the relevant awards or
workplace agreements require that it be referred to an external party.This party may be
specified in the award or agreement. Seek advice from your division or employer
group.
RACGP 4th edition Standards 4.1.1
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Practice Association and published by QIP/AGPAL july 2012
3
Occupational Health & Safety
(Customise as appropriate)
Policy
This practice is committed to preventing workplace injury and illness and ensuring a safe
and secure working environment for doctors, staff, patients and all other visitors.
We recognise that health and safety is an integral part of every activity we perform and as
such we maintain current knowledge of our obligations under State/Territory and Federal
WH&S legislation and we understand that non compliance with these legal requirements can
result in being prosecuted and fined.
It is a legal duty of every workplace to maintain standards to protect the health, safety
and welfare of every person within the workplace. This includes staff, patients, visitors
and anyone else who may enter the premises.
As an employer we must provide a safe and healthy workplace for our workers and
contractors.
All our workers have a duty of care to ensure that they work in a manner that is not
harmful to their own health and safety and the health and safety of others.
Effective WHS regulation requires that WorkSafe provides clear, accessible advice and
guidance about what constitutes compliance with the Act and Regulations.
Procedure
This practice has a designated elected health and safety representative (HSR). The name
and telephone extension of our HSR is kept <<insert location>>. Information relating to
WH&S issues is communicated to other staff via <<insert communication method>> and
updated regularly by the HSR. We consult with employees on matters that may directly
affect their health, safety or welfare and the HSR, is also involved in the consultation
We have current workplace Injury Insurance. Our practice keeps a record of all workrelated injuries and illnesses. All near-misses are also recorded in the register. The register
is located <<insert location>>.
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All incidents which cause of could have caused serious injury or deaths are made known to
Worksafe by contacting 13 23 60.
Incidents or accidents are also investigated internally by the <<Practice Manager/
Supervisor/ Business Owner>>. Corrective action is then taken to prevent the incident
occurring again and any changes are communicated to all staff.
To support the safety health and wellbeing of our practice team we have policies and
procedures in the following areas:

tasks involving manual handling are identified and measures are taken to reduce or
eliminate the risk of injury to doctors and staff as far as reasonably practical.

incidents and all injuries involving all staff and patients and others that occur in the
workplace are documented and managed professionally and ethically, according to
relevant medical standards and guidelines.

at induction and periodically all staff are instructed in safety and infection control
protocols ensuring risks are known and precautions taken, including staff
immunisation.

we strive to work together to maintain a safe physical work environment and that
supports the health and wellbeing of doctors, staff, patients and visitors. Including
ensuring regular breaks, adequate staffing levels and a smoke free environment.

we have a duty of care to safeguard the health of employees which also covers
psychological as well as physical health.

we strive to encourage consultation between management and staff on all matters
pertaining to OH&S matters as obligated under the legislation.

we endeavour to provide a working environment in which all doctors, staff, patients
and visitors are not subject to unlawful discrimination, sexual harassment, violence
or bullying.

audits are undertaken to ascertain that all practice and office equipment is
appropriate for its purpose. Records of maintenance, including electrical safety
checks and calibration schedules are maintained.
26
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
records of updates and training provided to all staff in relevant equipment operation
and maintenance, manual handling skills, and compliance with WH&S
requirements are maintained.

we strive to ensure the practice environment and facilities are adequate, and provide
for the comfort, safety and security of doctors, staff, patients and visitors.

we do not tolerate violence of any nature.

non medical emergency procedures and fire safety precautions are clearly
documented and designated members of the emergency team have a reference and a
basis for their decisions and actions within that role.

we have appointed one member of staff with primary responsibility for the
development and consistent implementation of our infection control systems and
procedures which includes environmental cleaning. Specific areas of responsibility
may be delegated to nominated members of the practice team and these particular
responsibilities should be documented in the relevant position descriptions.

to minimise harm to our patients we have clear lines of accountability and
responsibility for the delivery of safe and effective quality care.

we have a requirement for two members of the staff to be present during the normal
opening hours of the practice.
Handling Hazardous Substances






we implement arrangements for the safe use, handling, storage and transport of
chemicals and hazardous substances.
regular audits of products used by the practice are undertaken and hazardous
substances are stored, handled and documented according to assessed risk.
the practice endeavours to control risk associated with the use of hazardous
substances which are stored in labelled containers.
a register of hazardous substances is kept and maintained by the practice. (see hint
above about this).
staff members are instructed on how to handle hazardous substances appropriately
and documentation and ongoing training is provided regarding this.
regular risk assessment is undertaken by this practice in order to control risk
associated with the use of hazardous substances.
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Procedure
Material Safety Data Sheets (MSDS) are kept for all chemicals stored on site. They are
accessible to all staff and are kept <<insert location>>. MSDS detail the correct use,
storage and action to take when exposure to chemicals occurs.
MSDS sheets are available by contacting the supplier. A list of practice suppliers
including their contact details is kept <<insert location>>. All chemicals are used in
accordance with manufacturers instructions.
It is the responsibility of <<insert person responsible>> to ensure that the MSDS sheets
are available and updated when necessary.
All containers of chemical agents are appropriately labelled. This is to ensure that the contents
of containers can be readily identified and used correctly. For this reason, labels must be kept
fixed to the container at all times and clearly understood.
Specifically, it is recommended that a container with diluted cleaning agent state:



name, type and purpose of chemical agent
instructions on preparing and discarding the solution
warnings and/or health and safety instructions.
Containers of chemicals are stored in a cupboard out of the reach of children. If the cupboard
is below the waist, a childproof lock should be fitted.
Staff members who are required to handle chemicals are trained in their correct and safe use,
and this includes the correct use of personal protective equipment (PPE).
All chemicals and cleaning equipment are used for the purpose intended and in accordance
with the manufacturers instructions and dilution ratios are strictly adhered to.
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Our practice has the listed chemical and cleaning products for the following uses:
Product
Use
Storage location
MSDS
available
RACGP 4th edition Standards 4.1.2 & 5.3.3
3.1
Manual Handling
(Customise as appropriate)
Policy
Manual handling is any activity requiring the use of force exerted by a person to lift,
push, pull, carry, or otherwise move or restrain any animate or inanimate object. It
includes activities involving awkward posture and repetitive actions. Manual handling
injuries account for nearly 50% of all Workcover claims. The objectives of the
Occupational Health and Safety Manual Handling Regulations 1999, are to reduce the
number and severity of musculoskeletal disorders associated with tasks involving manual
handling.
Under these regulations, this Practice aims to identify tasks involving hazardous manual
handling and to undertake risk assessments. Risks to staff are thus reduced or eliminated
as far as practicable.
Procedure

avoid tasks that involve:
o twisting, bending or extensive reaching
o repeated or prolonged stooped posture
o lifting requiring extended reach
o repetitive lifts from below mid thigh or using forceful movements
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





o prolonged bent neck posture when working on low flat bench
o repetitive tasks for a prolonged time
o using excessive force to push, pull or hold object
reduce the size or weight of objects to be lifted or carried.
prevent slips or falls by wearing appropriate footwear.
ensure adequate lighting.
clean area regularly; spills should be wiped up immediately.
check equipment is in good working order and there is adequate space in which to
work.
weight limits: Seated – 4.5 kg. Standing – 16 to 20 kg. (For ideal conditions and
with a compact load held close to the body and with a short carrying distance).
Before doing any type of manual handling assess the situation ask the following
questions:
 should two people be lifting this or am I able to lift this safely and without risk or
injury?
 is my pathway clear of all objects?
 what distance am I going to be going?
 can I see clearly?
 can I split the load to make it lighter?
 size up the load – if in doubt seek assistance.
Our practice has one or more height adjustable examination couch/s to assist in the care
of patients with a disability, and to reduce the risk of staff injuring themselves when
assisting patients on or off the examination couch. Where our practice facilities are
inadequate for staff and visitors to safely assist patients with a disability we make
alternative arrangements. e.g. Home visits.
Staff Responsibility
If you identify a task, piece of equipment, or work area that may be a risk, report it to the
Practice Manager or the WH&S representative. A further detailed risk assessment will be
conducted and if necessary, changes will be made to reduce the risk of injury with
training for staff as needed.
RACGP 4th edition Standards 5.1.1, 4.1.2, 5.1.3
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
3.2
Incidents and Injury and Adverse Patient Events
(Customise as appropriate)
Policy
This practice has designated <<insert person responsible>> with primary responsibility for
clinical risk management including the following up of incidents, injuries and adverse patient
events and near misses.
It is a legal requirement under the WH&S legislation and for insurance purposes, to
report any injury sustained or thought to be sustained in the workplace, recognizing that
good reporting also leads to effective prevention.
Our practice encourages the identification, analysis and prevention of errors, failure or
inadequate systems that can potentially be a risk to patient safety to assist with risk
management strategies not to apportion blame.
Incidents that should be reported (regardless of whether harm has occurred) to assist with
making improvements to minimise the risk of recurrence, include:
 needle stick injury or mucous membrane exposure to blood or bodily fluids.
 Slip, trips or falls
 drug or vaccine incident (loss, misplacement or other).
 adverse patient outcome.
 failure or inadequate patient handover
 delayed treatment or follow up or unnecessary repeat of tests.
 Medication or prescribing errors.
 any deviations from standard clinical practice.
Accidents or incidents may involve the following:
 staff (employed directly by this practice).
 non-staff (patients, visitors, contractors).
 events (e.g. theft, non-patient assault, gas leak, bomb hoax, security breach,
medication error or patient complication following medical intervention, breakdown
in clinical handover).
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Actual and potential risks are identified and actions are taken to increase the safety and
improve quality care. The privacy of individuals involved is maintained. Every effort is
made to document the risk reviews and improvements made to the practice as a result.
Procedure
Staff use the <<insert form/reporting method>> to report any slips, lapses or near misses in
clinical care or deviations in patient care that might result in harm. The medical defence
organisation is contacted for events that might give rise to a claim.
Completed reports are:
 completed as soon as possible after incident occurs, preferably within 24 hours.
 Records are kept <<insert location>>
Any additional medical or other certificates, reports, pathology or other documents
related to the accident/incident are dealt with as soon as possible original documents are
submitted.
For injury occurring in the practice or course of work, WorkCover reporting protocols
must also be followed. It is a legal requirement to report all injuries sustained in the
workplace
The doctor should refer patients to another practitioner if there is a possible conflict of
interest, for example a staff WorkCover claim being managed by the employing
practitioner.
The staff member with designated responsibility in Risk Management conducts a
thorough review of all the hazards relevant to the cause(s) of any injury that has occurred
with a view to identifying appropriate controls.
Risk minimization techniques are then developed and implemented to reduce the risk of
reoccurrence. All documentation of the incident/event/near-miss is kept <<insert location>>.
RACGP 4th edition Standards 3.1.2
32
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Practice Association and published by QIP/AGPAL july 2012
3.3
Sharps Injury Management and Other Body Fluid Exposure
(Customise as appropriate)
Policy
The employer is responsible to ensure that all staff:






are familiar with the practice policy regarding management of blood and body fluid
exposure.
consider the blood and body substances of all patients as potential sources of infection.
understand how to prevent exposure to blood and body fluids.
have access to education and regular in service training in infection control matters.
have documented their immunisation status and have been offered NHMRC
recommended immunisations appropriate to their role.
analyse any incidents and modify procedures as required to reduce the risk of
recurrence.
In our practice, we understand that the management of occupational exposure to blood or
body fluids includes:





rapid assessment of the staff member and the source patient.
documentation of the incident.
counselling for the staff member.
timely administration of medications where appropriate.
investigation of the incident to enable modification of procedures if required.
Occupational exposure to needle stick injuries and body substances can be prevented by using
standard precautions, wearing personal protective equipment (PPE) and implementing safe
work processes.
Procedure
In the event of an occupational exposure, our practice will follow this procedure after
occupational exposure:
1. Clean/decontaminate
 skin: wash with soap and water
 mouth/nose/eyes: rinse well with water or saline.
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2. Notify the practice principal or GP on duty immediately
The source:
 explain and reassure the source and offer pre test counselling.
 obtain consent to have the source patient’s blood tested for Hepatitis B, Hepatitis C
and HIV
 the results should be available in 1-2 hrs if marked “urgent – needle stick” and
received at an appropriate testing laboratory.
 take a history from the source – maintain the source patient’s confidentiality and do
not interview them in front of relatives
o unprotected sexual intercourse
o sharing needles, tattoos, body piercing
o sharing razor blades or toothbrushes
o blood or body fluid exposure of mucous membranes or non intact skin.
o blood transfusion before Feb 1990 (for HCV)
o infection with HIV, HBV, HCV
o if the source patient has a history of at - risk activities inform them about the
window period in diagnosis.

if any of the staff member’s blood went into the patient or onto instruments that
were then used, the staff member also needs to be listed as a source.
The Exposed person
 if the source is unknown the person needs to be tested and post exposure prophylaxis
(PEP) needs to be considered
 obtain consent from the exposed person for urgent baseline testing for Hepatitis B,
Hepatitis C and HIV to establish if the staff member has previously acquired an
infection from other exposures.
 the exposed person’s confidentiality must be maintained especially if a staff
member.
 the exposed person may elect to have these tests performed at a different facility or
their own GP
 advise them to practice safe sex until their results and the source’s results and
history have been reviewed
 give the exposed person the telephone number for the state/territory Health
department communicable disease contact and other advisory services.
3. Treatment
 needs to be commenced if it is anticipated that the sources blood test results will not
be available within 24hrs and the source patient could be HIV positive or in the
window period.
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
if the HBV status of the exposed person is not known, and the sources HBV status
will not be available within 24-48 hrs then give:
o Hepatitis B immunoglobulin
o Hepatitis B Vaccination 1st Dose
o ADT (Adult Diphtheria and Tetanus)
the exposed health care worker should be referred for immediate consultation with
an infectious diseases specialist for consideration of PEP for HIV :
o if the injury is classified as high risk, or
o if the source patient has participated in at risk activities, or
o If the source patient is positive for HIV or other significant blood borne
infections.
o If the source patient is unknown

4. DocumentExposure:
We have appointed one member of staff with primary responsibility for the
development and consistent implementation of our infection control systems and
procedures. Report any exposure to this person or their delegated authority in addition
to normal incident reporting protocols. Report should include:

what procedure was being undertaken
how the injury happened and the name of anyone that witnessed it
the nature and extent of the injury
exactly what you were injured with (specify gauge of the needle)
the body substance involved
how much blood or body fluid was the health professional exposed to.
what personal protective equipment was being used?
the full name and address of the source. If the source cannot be identified document
“source patient not known”.







RACGP 4th edition Standards 5.3.3 & 3.1.2
3.4
Staff Immunisation
(Customise as appropriate)
Policy
We have appointed one member of staff with primary responsibility for the development and
consistent implementation of our infection control systems and procedures which includes
35
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Practice Association and published by QIP/AGPAL july 2012
staff immunisation.
All practice staff are advised of the risks of infection and are encouraged to be
immunised against vaccine-preventable diseases to prevent transmission of disease to and
from practice staff and patients when commencing employment with the practice. Staff
are also offered additional vaccinations where appropriate depending upon the likelihood
of their contact with patients and/or blood supply substances.
The practice will keep an extensive and up-to-date record of the immunisation history of
each staff member. This will assist in identifying non immune staff to ensure they are
excluded from contact with patients during disease outbreaks.
Subject to informed consent, the immunisation status of staff is known and recorded
including the documentation of any refusal. When a staff member has declared they’ve
had a vaccination, evidence, such as immunology reports, must be kept in the staff
record.
Staff are able to refuse immunisation or to refuse to declare their immunisation status and
this is recorded in their staff record.
Procedure
Upon commencement of employment, all staff are explained the risks and benefits of
immunisation in relation to their position. All staff are offered appropriate immunisation
if elected, according to the NHMRC recommended list for healthcare workers.
Immunisation records are signed and dated by both the administering GP and staff
member, These records are filed in the staff record and kept <<insert location>>.
If staff members declare they have already been immunised, immunity testing must be
carried out as this cannot be assumed. Additional immunisation may be recommended
based on the results of this testing.
Staff refusal to be immunised or refusal to disclose their immunisation status will be
documented and kept in their staff record.
RACGP 4th edition Standards 5.3.3 & 4.1.2
36
Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
3.5
Smoke-Free Environment
(Customise as appropriate)
Policy
As a prominent health care provider our aim is to promote the health and well being of all
staff, patients and others whilst they are on our premises.
Smoking is therefore not permitted in this practice and is discouraged on the premises or
the surrounding environment. The use of illegal drugs and alcohol is prohibited on and
around the site.
No smoking signs are visible in the waiting room and/or reception area. Signs are not to
be removed, except to replace worn or frayed items.
3.6
Staff Health and Wellbeing (including GPs)
(Customise as appropriate)
Policy
This practice is committed to providing and maintaining a safe and healthy workplace for
doctors, staff, patients and all other visitors. This includes psychological as well as
physical health.
Health and safety is an integral part of every activity we perform, and as such, the WH&S
of GPs and practice staff is a priority of this practice, and is governed by WH&S
legislation and regulations.
This practice recognises that that breaks may reduce fatigue and support the health and
wellbeing of both the General Practitioner and practice staff, as well as enhancing the
quality of patient care.
Our doctors and practice team can discuss concerns about violence in the practice and we
have the right to discontinue care.
To promote physical safety whilst at work, at least two staff members must be rostered at
all times. Our home visits and after hours policy has also been developed with staff safety
as an integral consideration.
37
Adapted by IWSML based on work produced by Dandenong Casey General
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Procedure
Our practice implements the following strategies to protect the health and wellbeing of staff:






workflow management strategies have been developed to deal with staff on
unexpected leave or who may be on leave for an extended period. The strategies are
known to all staff and are coordinated by <<insert the person responsible>>.
Scheduling of regular breaks for both practice staff and members of the clinic team
Enforcing a policy which does not allow team members to accrue a large amount of
leave and encourage regular leave periods.
Strategies to deal with violence which may occur in the practice including how to deal
with difficult patients, reporting systems and opportunities for counselling and
debriefing.
Strategies to deal with non-medical emergencies including evacuation procedures and
fire safety training for staff
During normal opening hours, at least two staff members are rostered/present at work
at all times.
RACGP 4th edition Standards 4.1.2
3.7
Practice Facilities
(Customise as appropriate)
Policy
The practice premises, including the facilities and equipment are safe and adequate to
meet the needs of the staff and patients.
The facilities at our practice make adequate provision for and encourage patient auditory
and visual privacy.
Facilities are well maintained and visibly clean with surfaces easilyible for cleaning.
Every reasonable effort is made to make the environment safe and comfortable for staff
and people who use the practice.
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Our waiting area/s are sufficient to accommodate the usual numbers of patients who
would usually be waiting at any given time.
Our practice has one or more height adjustable beds. The physical conditions in our
practice support patient privacy and confidentiality.
Procedure
Upon inspection of the practice, the following features can be observed:







Dedicated room for each clinical team member
Consultation rooms are quiet, adequately lit, comfortable and feature an
examination couch
The waiting room has sufficient space to manage the usual practice patient load
All equipment is safe and fit for purpose
Sensitive information or materials are kept in a secure location accessible only by
practice staff
Hand washing facilities and toilets are readily available for both patients and staff
and are kept clean
At least one height-adjustable bed is available within the practice
RACGP 4th edition Standards 5.1.1, 5.1.2, 5.2.1, 5.3.3
3.8
Security
(Customise as appropriate)
Policy
Our practice ensures as much as possible that our facilities provide appropriate security
for patients, staff and visitors. All practice staff are aware of, and are able to, implement
protocols to ensure the safety and security of all persons within the practice.
Procedure
During normal opening hours, there are at least 2 members of staff present.
39
Adapted by IWSML based on work produced by Dandenong Casey General
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The practice has implemented the principles in the RACGP Guide General Practice- A
Safe Place toolkit. All staff have been provided training in how to deal with difficult
patients and the security protocols of the practice during their induction.
The practice also makes available RACGP GP support programs. Security issues are
discussed regularly at staff meetings and all violent incidents are discussed and assessed
on a whole of practice level.
<<Customise as appropriate>>
Our practice has available a duress alarm system to notify all staff members if they are
experiencing a violent encounter.
It is the responsibility of the appointed Risk Management leader to ensure that these
policies and procedures are implemented and adhered to.
RACGP 4th edition Standards 5.1.1 & 4.1.2
3.9
Non Medical Emergencies
(Customise as appropriate)
Policy
Non medical emergencies may occur that will require a quick, informed and effective
staff response.
Types of non-medical emergencies include: failure of electricity supply, telephone or
water, fire or false fire alarm, property damage, break-in, abusive or threatening
telephone calls or persons at the practice, leakage of toxic chemicals, bomb threats and
letter bombs.
We also have a business continuity plan for unexpected events such as natural disasters,
national or local infection outbreaks or the sudden, unexpected absence of clinical staff or
computer system failures.
The practice has appointed a designated member of staff to have primary responsibility for
our risk management systems. These may include clinical and non clinical risks and events.
Specific areas of responsibility can be delegated to other nominated members of the practice
team and these particular responsibilities are documented in the relevant position descriptions.
40
Adapted by IWSML based on work produced by Dandenong Casey General
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Procedure
(Select the option most appropriate for your practice)
Option 1
Our practice has <<a non-medical emergency manual /documented emergency policies>>
which details the safety procedures to be undertaken during the specific emergency situations.
The manual/policies are located <<insert location>> and all staff have been made aware of
the manual during their orientation/induction. Designated members of the practice team have
been appropriately trained in procedures for emergency situations and these roles are
documented in their position descriptions.
Our business continuity plan has been developed to deal with unexpected events such as
natural disasters, power or business failures, or other unforeseen circumstances which may
impact on normal business operation. The business continuity plan was last tested on
<<insert date of test>>.
RACGP 4th edition Standards 4.1.2, 3.1.2, 4.2.2
41
Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
4 Infection Control
4.1
Principles of infection control
(Customise as appropriate)
Policy
Because many infectious agents are present in health care settings, patients may be infected
while receiving care, health care workers and others such as receptionists and cleaners may be
infected during the course of their duties or when working and interacting with patients and
other people. Potential infection risks to the practice team and our patients need to be reduced.
Our practice has implemented systems that minimise the risk of health care associated
infections including delegation of infection control and prevention responsibilities to a
competent staff member.
We have appointed one member of staff with primary responsibility for the development and
consistent implementation of our infection control systems and procedures.
Specific areas of responsibility may be delegated to nominated members of the practice team
and these particular responsibilities should be documented in the relevant position
descriptions (e.g.. infection control processes, sterilisation process, environmental cleaning,
staff immunisation, staff education).
Our practice has written polices relating to key infection control processes which are reviewed
and updated regularly.
All staff have an individual responsibility to identify any potential infection risks within the
practice and to be familiar with and implement the relevant infection control procedures of
our practice.
New staff, including contracted staff and casuals, are familarised with our infection control
policies that are appropriate to their duties as part of their induction to our workplace. Where
appropriate, their competency is assessed and this assessment recorded or evidence of
previous competency is obtained and recorded. Mechanisms are in place to ensure ongoing
education and competency occur on a regular basis or when changes occur to our procedures.
42
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Our practice remains alert to changes to guidelines for infection control, and can implement
them accordingly in a timely manner. We have a system for monitoring and obtaining
information about national and local infection outbreaks, as well as about emerging new risks
of cross infection and we have an effective mechanism for timely receiving and dissemination
of any important communication or updates about emerging diseases or infection control
measures to all relevant staff.
Procedure
We have a designated staff member <<insert staff members name>> who has responsibility
for co coordinating and sustaining our infection control processes. This includes:
 continually modifying and improving our procedures and written policies in accordance
with the most recent evidence and guidelines and adopting a risk management approach
when implementing infection control measures.
 ensuring the timely dissemination of information concerning changes to infection
control procedures or information about national and local infection control outbreaks.
 maintaining staff knowledge, education and competency in infection control activities
and ensuring the consistent implementation of our infection control policies and
procedures.
 ensuring the practice remains visibly clean and environmental cleaning processes are
documented.
 appropriate delegation of infection control responsibilities and documentation of such
delegation
To ensure consistency of workplace practices our policy and procedure manual contains the
following written infection control protocols:
 prevention of disease in the workplace by staff immunisation.
 blood and body fluid spills management.
 sharps injury management
 hand hygiene.
 a cleaning schedule for clinical and non clinical areas of the practice which describes
the
 frequency of cleaning, products to use and person responsible. Where appropriate we
have documented evidence of cleaning activity.(Refer to section 5).
 procedures for all aspects of the provision of sterile instruments whether by the use of
disposables, or by onsite or offsite sterilisation.
 safe storage and stock rotation of sterile products.
 procedures for waste management including the safe storage and disposal of clinical
waste and general waste.
 the appropriate use and application of standard and additional precautions.
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




access for patients and staff to Personal Protective Equipment (PPE) including
evidence of education on the appropriate
application, removal and disposal of PPE.
triage of patients with potential communicable diseases.
pathology testing done within the practice.
ongoing education and training provided to each staff member and the mechanism for
assessing staff competency in infection control procedures.
RACGP 4th edition Standards 5.3.3 & 4.1.1
4.2
Blood and body fluid spills
(Customise as appropriate)
Policy
Our practice has management systems for dealing with blood and body substance spills.
 blood and body fluids, including blood, vomit, urine, faeces, sputum and body tissue are
treated as potentially infectious substances that can transmit disease should contact
occur.
 doctors, nurses, other health professionals, practice staff and external contractors (e.g.
cleaners) consistently use standard precautions to achieve a basic level of infection
control regardless of the known or perceived infection status of the patient.
 any spillage needs to be treated promptly to reduce the potential for contact with other
patients, staff or visitors.
 the designated infection control leader is responsible to ensure all staff are familiar with
the practice’s policy and procedure for the management of blood and body fluid spills
and staff receive adequate training on how to appropriately clean blood and body
substance spills which is appropriate for the tasks they are expected to perform.
 staff are also familiar with the actions to take in the event of exposure to blood or body
fluids while cleaning a spill.
Our practice has a spills kit readily available consisting of a rigid walled container with a lid
and contains:




1 small bucket (with water level marked) and pre-measured amount of detergent* (in a
labelled container) to be made up when necessary.
utility rubber gloves.
face and eye protection: Goggles/safety glasses/face shield/mask.
disposable or reusable impermeable/plastic apron/gown.
44
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






roll of paper towelling (that retains strength when wet).
scrapers (2 pieces of firm cardboard or plastic).
hazard/cleaning sign.
biohazard bag.
polymerising beads or other absorbent material.
list of contents to assist restocking after use.
copy of the instructions for cleaning spills.
*The detergent used for general cleaning is satisfactory for treating most spills
(Source: Infection control standards for office based practices, 4th Edition)
Procedure
As part of the induction process all staff are provided with information about our practice’s
protocol for managing spills of blood and body.
In our practice, the Spills Kit is located (*insert the location of the Spills Kit here).
It is the responsibility of all staff members who use the spills kit to ensure all items are
replaced after each use and the items are not expired. If additional or replacement stock is to
be ordered, <<insert staff member responsible for ordering equipment>> is informed.
Disposable items in the Spills Kit must be replaced after each use and reusable items cleaned
according to protocol.
The management of spills should be flexible enough to cope with different types of spills,
taking into account the following factors:





the nature of the spill
the pathogens most likely to be involved in these different types of spills
the size of the spill
the type of surface
the area involvedthe possibility of some material remaining on a surface where cleaning
is difficult (e.g. between tiles) and of bare skin contact with that surface.
Only staff with confirmed vaccination status and training are permitted to clean spills of blood
or body fluid and perform other high risk activities such as instrument reprocessing. (Refer to
Section 3 Staff Immunisation)
Spot spill
Practice procedure
45
Adapted by IWSML based on work produced by Dandenong Casey General
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In our practice, this procedure is followed when cleaning a spot spill:
1. don PPE as considered appropriate
2. quarantine area
3. use disposable paper to absorb the bulk of the blood and body fluid
4. wash the surface with warm water and a neutral detergent
5. dry thoroughly with a clean wipe
6. dispose of waste in the infectious waste container
7. if broken glass or any other sharp is involved it must be picked up with forceps and
disposed of in a sharps container before cleaning and disinfection is attempted.
Small or large spill
Practice procedure
In our practice, this procedure is followed when cleaning a small or large spill:
1. don PPE as considered appropriate
2. quarantine area
3. absorb the spill with paper towel and dispose of as clinical waste.
4. clean the surface with detergent and water. Where there is the possibility of some material
remaining on a surface where cleaning is difficult (eg between tiles) and there is a possibility
of bare skin contact with that surface, then a disinfectant may be used after the surface has
been cleaned
with detergent and water. The contaminated surfaces should be treated with a disinfectant
(Sodium Hypochlorite solution - 1000 parts per million of available chlorine, usually
achieved by a 1 in 50 dilution of 5% liquid bleach or (Milton - 1% sodium hypochlorite –
used as 1:10) Granular chlorine: e.g., Det-Sol 5000 or Alcohol: e.g, Isopropyl 70%, ethyl
alcohol 60%. Always read manufacturer’s instructions and precautions. (eg Sodium
Hypochlorite is corrosive to metals and alcohol highly inflammable, hardens plastic and
swells rubber)
5. leave the solution on the surface for a minimum of 10 minutes or as directed by the
manufacturer.
6. clean the surface again to remove the sodium hypochlorite if used.
7. dry thoroughly.
46
Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Carpet
Practice procedure
In our practice, this procedure is followed when cleaning a spill on carpet:
1. blot up as much of the spill as possible using disposable towels, and then clean with a
detergent
2. arrange for the carpet to be cleaned with an industrial cleaner as soon as possible.
RACGP 4th edition Standards 5.3.3
4.3
Hand washing and hand hygiene
(Customise as appropriate)
Policy
Effective Hand hygiene has been proven to reduce the spread of infection. This minimises the
risk of cross-contamination through physical contact with patients and co-workers as well as
touching inanimate objects such as door handles and telephones.
Gloves are not a substitute for hand cleaning. Fingernails are to be kept short and clean with
jewellery kept to a minimum as these may harbour bacteria. Cuts and abrasions are covered
with water resistant dressings. Nailbrushes are not used.
The employer is responsible to ensure all staff members have been educated on effective hand
hygiene and hand care.
Staff must wash their hands:






before and after examining and treating
patients
before and after and between performing
any procedure
before and after taking blood,
before and after giving an injection
after handling pathology specimens
after handling any equipment that might
have been soiled with blood or other
body substance

after routine use of gloves

before and after eating

before and after smoking
after blowing your nose
after going to the toilet
when visibly soiled or perceived
to be soiled



47
Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Easy access to hand hygiene facilities is promoted with dedicated hand washing facilities
(with hot and cold water, liquid soap and single use paper towel) readily available in every
clinical management or treatment area.
Hand disinfectants designed for use without water, such as alcohol based hand gel can be used
in the following situations:




emergency situations where there may be insufficient time and/or facilities e.g. in the
doctors bags.
when hand washing facilities are inadequate, e.g. reception areas, home visits.
in all treatment and examination areas to encourage hand hygiene in addition to hand
washing facilities.
In patient and staff areas during flu season to encourage hand hygiene.
Signage is displayed in areas where hand hygiene facilities exist to encourage proper hand
washing techniques.
Visible soil must be removed with detergent based wipes first. If significant direct physical
contact with a patient or patient’s blood or body fluids is likely to occur this should ideally
take place in an area where access to hand washing facilities is available.
Hand Hygiene products need to be selected with consideration of the following factors:




type of hand hygiene requires i.e. routine, aseptic (clinical), or surgical.
the location of the product.
compatibility of agents if multiple agents are used e.g. hand creams, ointments.
care and protection of staff hands and sensitivities.
There is no soap bars utilised in our practice. Where possible liquid hands wash dispensers
with disposable cartridges, including a disposable dispensing nozzle, are used; where these
are not available a pump pack is used. These are never topped up and are ideally discarded
when empty. Should they need to be refilled, the container is washed and dried thoroughly
prior. The nozzle is kept clean and free of dried soap.
Appropriate facilities for drying hands are provided. Hot air dryers are not used in clinical
areas. Single use towels (paper or cloth) are provided in shared locations and clinical areas.
Disposable paper towel is used prior to aseptic procedures. Hand moisturiser is made
available for staff use.
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Procedure
Routine hand cleaning for soiled hands
The following procedure is followed for a routine hand wash:
1. wet hands thoroughly and lather vigorously using liquid soap.
2. wash for 10-15 seconds.
3. rinse thoroughly.
4. dry with paper towel or single use cloth towel.
5. use paper towel to turn taps off if not ‘hands free’.
Hand Washing for aseptic (non-surgical or clinical) procedures
The following procedure is followed for a non-surgical hand wash:
1. wash hands thoroughly using neutral liquid soap or an anti-microbial cleaner (e.g. 2%
Chlorohexidine).
2. wash for 1 minute.
3. rinse thoroughly.
4. dry thoroughly with paper towel or single use cloth towel.
5. use paper towel to turn taps off if not ‘hands free’.
Hand washing prior to surgical (invasive) procedures
The following procedure is followed for a surgical hand wash:
1. Remove Jewellery
2. Wet hands and forearms
3. Wash hands, nails and forearms thoroughly with an antimicrobial cleaner
i. (e.g. 4% chlorohexidine, 0.75% detergent based povidine or 1% aqueous povidine)
4. First wash 5 minutes and each subsequent wash 3 minutes
5. Rinse carefully keeping hands above the elbows
6. Do not touch taps (ask another staff member to do this if not ‘hands free’.
7. Dry thoroughly with sterile paper or cloth towels.
Location
hand washing
facilities
Patient toilets
Liquid soap
Paper towel/air
dryer
Equipped for
routine hand
washing
yes
Equipped for
aseptic hand
washing
no
Equipped for
Surgical hand
washing
no
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Adapted by IWSML based on work produced by Dandenong Casey General
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Consulting rooms
Treatment room
Liquid Soap
Antimicrobial
cleaner (2%
Chlorhexidine)
Paper towel
Liquid Soap
Antimicrobial
cleaner (4%
Chlorhexidine)
Paper towel
Sterile towel
yes
yes
no
yes
yes
yes
RACGP 4th edition Standards 5.3.3
4.4
Single Use Equipment
<<Delete this section if your practice does not use disposable equipment>>
(Customise as appropriate)
Policy
Equipment and medications labelled by the manufacturer as disposable or single patient use
are not reprocessed (cleaned) or re-used in this practice.
Single use packaging is the only acceptable presentation for dressings, suture materials, suture
needles, hypodermic needles, syringes and scalpels.
Single use vials should be used in preference to multi dose vials of injectable substances as
multi dose vials present an infection hazard if incorrectly used.
Items marked by the manufacturer as “single use” must never be reused under any
circumstances. Some items may be reprocessed for use by the same patient if labelled “single
patient use” and in this case the manufacturer’s instructions for reuse must be followed. These
may include cleaning requirements and limitations to the number of times the item can be
reprocessed.
Single use items or equipment contaminated with blood or body fluid are considered clinical
waste and are disposed of accordingly.
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Where possible saline solution and skin preps are purchased in single use sachets or
containers. Larger containers, if used, are dated when opened and changed regularly.
Procedure
<<Select the Option that is most applicable to your practice>>
Option 1:
Our practice does not use reusable medical equipment. All instruments are disposable.
It is the responsibility of all staff to ensure that soiled or contaminated disposable instruments
are placed in the correct sharps disposables bins after each use.
Appropriate PPE must be worn when using equipment.
Option 2:
Our practice uses a combination of single-use and reusable disposable equipment.
All single-use equipment is disposed of in an appropriate manner directly after use in the
correct sharps disposal bins.
Reusable equipment is reprocessed according to the manufacturer’s instructions. Further
instructions on equipment processing are located later in this section.
It is the responsibility of all staff to ensure the equipment they are using is disposed of
according to their classification and in accordance with practice policies and procedures.
RACGP 4th edition Standards 5.3.3
4.5
Offsite Sterilisation
<<Delete this section if your practice does not use offsite sterilisation services>>
(Customise as appropriate)
Policy
Our practice uses an offsite sterilisation process to ensure that equipment is appropriately
cleaned and sterile for use with patients.
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Our practice uses the services of <<insert service provider name>>. Validation of the
sterilisation process occurs annually and copies of records are kept <<insert location of
sterilisation records>>.
The following documentation is maintained:
 a copy of the offsite facilities current accreditation certificate (e.g. accredited general
practice or ACHS accredited hospital).
 our procedures for safe transport of instruments and equipment to and from the offsite
facility.
 an agreement between our practice and the off site sterilisation facility stating who is
responsible for washing and packaging items, transport, turnaround time, quoted prices
and names of contact people for both organisations.
 evidence that the offsite facility correctly performs the sterilisation and validates it
processes.e.g. validation documentation or certification provided annually.
Our practice has appropriate policies and procedures to ensure preliminary cleaning of
items, packaging and transportation arrangements including evidence of staff training and
competency.
Procedure
It is the responsibility of <<insert the person’s name>> to co-ordinate the off site
sterilisation arrangements.







ensure that all instruments that require sterilisation are cleaned in accordance with the
documented procedure.
items are packaged and labelled prior to despatch to the facility in accordance with the
documented procedure
place all instruments in a plastic container labelled “contaminated” with a firmly fitting
lid. If items are not cleaned prior, standard precautions must be adhered to when
handling this container and contents.
document all instruments leaving the practice.
telephone to inform the offsite sterilisation service provider that a cycle of instrument
sterilisation needs to be undertaken for our practice and to arrange a delivery and pickup time
use a different plastic container “labelled sterilised items” to collect the items from the
sterilisation facility
on return of the instruments following sterilisation, check the packages for damage
thoroughly before signing off.
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Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Packaging of Items for offsite sterilisation.
Procedure
Our practice ensures the packaging of items for sterilisation provides an effective barrier
against sources of potential contamination in order to maintain sterility and to permit
aseptic removal of the contents at point of use.
A copy of the procedure for packaging items is located with the packaging materials so all
staff can readily refer to these instructions. All staff follow this procedure when packaging
instruments.
53
Adapted by IWSML based on work produced by Dandenong Casey General
Practice Association and published by QIP/AGPAL july 2012
Step 1
Visually check items have been cleaned and dried, and are in good working
condition and free of rust or surface damage
Step 2
If your workplace uses specific sets then group items according to your
protocols.
Step 3
Insert the items into the package considering the following principles
Step 4

Ensure package is the appropriate size for required items.

Open and unlock items with hinges or ratchets.

Package in a manner that prevents damage to items or injury to end user
and facilitates steam movement across the surface of items.

Use tip protectors if necessary to prevent sharp instruments from
perforating the packaging.
Check each package has a class 1 indicator integrated on the packaging.
(Steriliser indicator tape or a separate class 1 indicator must be used if absent
on the packaging material.)
Step 5
Select Option 1 Remove peel-off strip from pouch, and fold precisely along the
marked line to seal the pouch
Or Option 2:
Cut packaging from roll and fold each end over twice. Apply sterilisation tape
(usually has a class 1 indicator stripe) to seal over the fold extending it around
the edge of the package.
Step 6
Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with

Initials of the person packaging the item

Date of sterilisation & load number (this may be added prior to loading the
steriliser if not known).

Contents of the package (if opaque packaging).
Step 6
Inspect pack to ensure packaging material is intact.
Step 7
Store item/s in a container with lid, cupboard or drawer, clearly marked as
“unsterile items” until ready to load into the steriliser.
54
Adapted by IWSML based on work produced by Dandenong Casey General
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4.6
Onsite Sterilisation
<<Delete this section if your practice does not sterilise equipment onsite>>
(Customise as appropriate)
Policy
This practice is able to provide assurance that any items provided for procedures into
normally sterile tissue, sterile cavities or the bloodstream are sterile.
This practice understands that sterilisation is more than simply putting loads through a
steriliser and the process of sterility assurance includes all aspects of equipment reprocessing,
and staff education.
Our practice has a supply of reusable instruments that are maintained in good working order
and are free of rust and surface damage. The correct procedures must be followed to ensure
that these instruments are cleaned and sterilised after each use. Our practice uses steam at
high temperature under pressure for sterilising cleaned instruments. This is the most reliable
and cost effective method of sterilisation and is recommended for use in general practice.
Specific instructions on the packaging and use of the autoclave are kept <<insert the
location>>. These instructions must include a comprehensive workflow schedule to ensure
that there is no possible contamination of the clean areas where the sterile instruments are
unloaded and stored.
All items to be sterilised must be thoroughly cleaned first. Our practice documents each cycle
in a sterilisation log.
Our portable steam steriliser has a closed door drying cycle that must be used when
processing wrapped articles so as to ensure that instrument packs are dry before unloading.
Our practice validates our sterilisation process annually at the servicing of the steriliser.
<<Insert name of staff member>> is responsible for correct operation and training staff on
how to process instruments.
All staff are aware of the processing time required and the maximum load limits as
determined by the validation process
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Adapted by IWSML based on work produced by Dandenong Casey General
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Holding times for steam sterilisation
All times are based on the assumption that the items to be sterilised are thoroughly clean.
Temperatu
re @ C
Pressure
Holding time for
steam
sterilisation (this
includes safety
factor)
KPa
psi
121C
103
15
15 minutes
126C
138
20
10 minutes
134C
(wrapped
items)
203
30
3 minutes
Penetration
time if
applicable (as
determined by
technician)
Total
Sterilisation
Time
The “holding time” does not include:
 the time taken for heating the load to the desired temperature
 any large volumes of material or heavily wrapped/packaged items included in a given
load, and
 time taken to allow the inside of the packs to achieve the desired temperature.
This is the “Penetration time” and must be added to the holding time.
STERILISATION TIME = PENETRATION TIME + HOLDING TIME.
Packaging of items for sterilisation
Policy
Our practice ensures the packaging of items for sterilisation provides an effective barrier
against sources of potential contamination in order to maintain sterility and to permit aseptic
removal of the contents at point of use.
A copy of the procedure for packaging items is located <<insert location of the procedure
document>> so all staff can readily refer to these instructions. All staff follow this procedure
when packaging instruments.
Items that are being sterilised for disinfection but which do not need to be kept sterile for
reuse can be processed unwrapped e.g. vaginal speculums
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Procedure
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 6
Step 7
Visually check items have been cleaned and dried, and are in good working
condition and free of rust or surface damage
If your workplace uses specific sets then group items according to your
protocols.
Insert the items into the package considering the following principles
 Ensure package is the appropriate size for required items
 open and unlock items with hinges or ratchets
 Package in a manner that prevents damage to items or injury to end user
and facilitates steam movement across the surface of items
 use tip protectors if necessary to prevent sharp instruments from
perforating the packaging
Check each package has a class 1 indicator integrated on the packaging.
(Steriliser indicator tape or a separate class 1 indicator must be used if absent
on the packaging material.)
Select
Option 1. Remove peel-off strip from pouch, and fold precisely along the
marked line to seal the pouch
Or Option 2.
Cut packaging from roll and fold each end over twice. Apply sterilisation tape
(usually has a class 1 indicator stripe) to seal over the fold extending it around
the edge of the package.
Use a felt-tip, non-toxic, solvent-based marker pen to label the pack with
 initials of the person packaging the item
 date of sterilisation & load number
 (this may be added prior to loading the steriliser if not known)
 contents of the package (if opaque packaging).
Inspect pack to ensure packaging material is intact.
Store item/s in a container with lid, cupboard or drawer, clearly marked as
“unsterile items” until ready to load into the steriliser.
4.7.1 Instrument and equipment processing area
(Customise as appropriate)
Policy
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The RACGP Standards recommend a designated area should be used for processing all
instruments and equipment for reuse to prevent possible contamination of processed items.
A workflow pattern, systematically moving from dirty to clean, must be established within the
designated area. All staff must understand and adhere to the designated work flow pattern.
The workflow pattern must enable items to progress from the cleaning area to the steriliser
packaging/unloading and sterile stock storage area without re-contamination.
The equipment processing area needs to include:




adequate bench space with surfaces made of a smooth, non-porus material without
cracks or crevices to allow for cleaning
good lighting
bins for specific waste
adequate storage space for materials and equipment.
Specified cleaning equipment such as:
1. heavy duty utility gloves, plastic apron to protect clothing, protective eyewear and if
items are grossly soiled, a mask or visor.
2. a non-corrosive, non-abrasive, free rinsing and mildly alkaline detergent in the original
container or a clean, well labelled bottle.
3. cleaning brushes of a suitable size to effectively reach all parts of the item being
cleaned.
4. low-linting towelling for drying the cleaned items.
This area, including sinks and containers need to be cleaned daily.
Procedure
In our practice, our equipment processing area is located (*insert location here) and our
facilities include:
(Select from option 1, 2 or 3 depending on which best describes your practice equipment
cleaning facilities. Delete other options and return italic text to normal)
(Option 1). Dedicated double sink with adequate bench space either side for work to flow
from dirty to clean area. A separate hand washing area is also available elsewhere in the
room.
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


use the sink on the dirtiest side (according to the workflow pattern) to wash the dirty
instruments with the plug inserted. This is the dirty sink.
use the other sink to initially rinse the instruments and then for the final rinse. Do not
insert the plug but rinse under running water.
use the separate hand washing area for hand cleansing
(Option 2). A double sink with adequate bench space either side for work to flow from dirty to
clean area. This sink is also the only area available for hand washing.



obtain and label a large plastic container to act as the dirty sink and place this on the
dirtiest side (according to the workflow pattern) of the existing sink.Use this container
to wash the dirty instruments in.
use the sink directly adjacent to initially rinse the instruments and then for the final
rinse. Do not insert the plug.
use the second adjacent sink as a dedicated hand washing area.
OR



use sink can also be used for washing hands. However, it must be cleaned after
washing the sink on the dirtiest side (according to the workflow pattern) to wash the
dirty instruments with the plug inserted. This is the dirty sink.
use the other sink to initially rinse the instruments and then for the final rinse. Do not
insert the plug but rinse under running water. This is the clean sink.
the clean instruments to render it suitable for hand washing.
(Option 3). A single sink available to use for cleaning items, Separate hand washing facilities
are available.



obtain and label a large plastic container to act as the dirty sink and place this on the
dirtiest side (according to the workflow pattern)of the existing sink .Use this container
to wash the dirty instruments in.
use the sink to initially rinse the instruments and then for the final rinse. Do not insert
the plug.
use the separate hand washing area for hand cleansing
(Option 4). A single sink is available to use for cleaning items and washing hands.

obtain and label a large plastic container to act as the dirty sink and place this on the
dirtiest side (according to the workflow pattern)of the existing sink .Use this container
to wash the dirty instruments in.
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

use the sink to initially rinse the instruments and then for the final rinse. Do not insert
the plug
the sink can also be used for washing hands. However, it must be cleaned after
washing instruments to render it suitable for hand washing.
Environmental Issues
The area and equipment associated with instrument and equipment processing:



is only cleaned or managed by appropriately trained Practice Staff.
must remain in a clean and tidy manner throughout the day.
is thoroughly cleaned at the end of the day.
If a plastic utility container is used as the Dirty sink for washing the instruments this container
must be treated with due care. The container is not touched with ungloved hands and it is
thoroughly washed at the end of the day as part of the practice’s routine cleaning. This
container is not to be used for any purpose other than instrument pre-cleaning
RACGP 4th edition Standards 5.3.3
4.7.2 Cleaning reusable Instruments and equipment
(Customise as appropriate)
Policy
A basic risk assessment is required to determine the appropriate level of processing required
for specific instruments. The site/manner where an instrument will be used can assist in
determining the risk of infection. This analysis determines the level of processing required to
minimise the probability of infection to the patient.
More information to assist with this risk assessment can be obtained from RACGP Infection
Control Standards for Office Based Practices, 4th Edition (page 51).
In our practice, we have a designated staff member responsible for sterilisation in our
practice. It is part of their role to ensure all staff who are sterilizing instruments are adequately
trained and competent in the procedure.
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More information about aspects that require training and competency can be obtained from
RACGP Infection Control Standards for Office Based Practices, 4th Edition (page 52).
Thorough physical cleaning of items to remove blood and other debris is needed if effective
disinfection or sterilisation is to be achieved. Preliminary cleaning must be done as soon as
possible during or after use to prevent coagulation of blood and other proteins.
Any delay will increase the bio-burden (through bacterial multiplication) and also increases
the difficulty of removing adherent soil. The effectiveness of sterilisation is dependent on the
bio-burden being as low as possible.
Procedure
In our practice, the designated leader for sterilisation is <<insert name of person
responsible>>.
All staff cleaning reusable items must:




wear appropriate PPE.
use equipment as specified.
have received appropriate formal or in house training.
be appropriately immunised.
Our practice follows this procedure for all instruments and equipment that is going to be
reused for patient care. This includes items that need to be:
 clean but are not required to be sterile for re-use e.g. kidney dishes, ear syringes.
 sterilised after use, but not used as sterile e.g. vaginal speculums.
 sterile for re-use e.g. surgical instruments.
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Step 1
Wash hands with liquid soap and dry thoroughly with paper or single use
towel.
Step 2
Put on personal protective equipment including goggles, plastic apron and
heavy duty kitchen gloves.
Step 3
During or immediately after use open instruments and, dry- or damp-wipe
off gross soil. Rinse the item under gently running tepid water over the
clean sink.
Step 4
If unable to clean instruments immediately, open instruments and soak in
a container with a lid in tepid water and detergent until they can be
cleaned. Clean instruments as soon as possible as prolonged soaking
damages instruments. Use fresh water and detergent
Step 5
Prepare dirty sink/basin by filling with sufficient tepid water and the
correct amount of detergent to cover the items being washed.
Step 6
Thoroughly wash each instrument in the dirty sink/basin to remove all
organic matter. Open and disassemble items to be cleaned. Keeping items
under the waterline to minimise splashing and droplets, scrub items with a
clean, firm-bristled nylon brush. Use a thin brush to push through lumens,
holes or valves.
Step 7
Rinse the washed instruments in gently running hot water over the clean
sink/basin.
Step 8
Inspect instruments to ensure they are clean. Look at hinges, handles and
working surfaces.
Step 9
Place each washed instrument on a clean lint free cloth or surface and
repeat the above process until all instruments have been cleaned and
rinsed.
Step 10
Carefully discard dirty water down the sink. If using a container, aim to
pour the dirty water directly into the plughole rinsing the sink afterwards
with running water.
Step 11
Wash cleaning brushes/cloths with detergent and tepid water after every
use. Hang to dry. Can consider sterilising these in the last load of the day.
Step 12
Wash the dirty and clean sink/basin by rinsing it with tepid water and
detergent. Wipe down the sink/basin with a disposable towel.
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Step 13
Remove kitchen gloves and replace with non sterile disposable
gloves...Carefully dry each instrument with a clean, lint free cloth. Do not
allow to air dry.
Step 14
Remove and Clean personal protective equipment by washing or wiping
down and drying.
Step 15
Wash hands with liquid soap and dry thoroughly with paper or single use
towel.
RACGP 4th edition Standards 5.3.3
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4.7.3 Loading the steriliser
(Customise as appropriate)
Policy
Correct loading of sterilisers is needed for successful sterilising to:







allow efficient air removal
permit total steam penetration of the load
allow proper drainage of condensation and to prevent wet loads
prevent damage to items in the load
maximise efficient utilisation of steriliser
when loading the steriliser, care needs to be taken that the steam can circulate
effectively and that all surfaces are accessible and exposed to steam.
never exceed the validated load <<insert location where details of the validated load
can be found e.g. on the wall near the steriliser>>
Step 1
Load items into the steriliser following these points:
allow enough space between each item to allow air removal,
steam penetration and drying to occur
do not crush items together
do not allow items to touch the floor, top or walls of the chamber
Follow the pattern of loading described in the practice validation
protocol when doing a full load.
Step 2
Fill the chamber with or ensure reservoir has sufficient
deionised/demineralised water as per the manufacturer’s instructions.
Step 3
If the steriliser allows you to select different loads check that the
appropriate load parameters are selected.
Step 4
Monitor the sterilisation process by one of the following:

automatic printout or computerised data logger download
(records at a minimum of 60 second intervals).
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
use of a class 4, 5 or 6 chemical indicator with every cycle.

Manually record time and temperature throughout the cycle at least
every 30 seconds.
Step 5
Close and secure chamber door as per manufacturer’s instructions.
Step 6
Press “Start” button or relevant button to commence the cycle as per
manufacturer’s instructions.
Pro
ced
ure
Our practice follows this process when loading the steriliser:
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4.7.4 Unloading the steriliser
(Customise as appropriate)
Policy
For packaged items, the period of time between their removal from a steriliser (any type) and
their return to room temperature is recognised as being the most critical time with respect to
assurance of sterility.
Cooling generates a tiny flow of room air into the pack at flow rates demonstrated to breach
porous packaging materials leading to their failure to provide a microbiological barrier.
Correct cooling practice is needed to maintain sterility. When a sterile item is not cooled in
the correct manner the article can have moisture build up, which can contaminate stock. The
item must be reprocessed if the packaging is torn, punctured or wet.
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Procedure
Our practice follows this process when unloading the steriliser:
Step 1
When cycle is complete, check printout, data logger, or Class 4, 5 or 6
chemical indicator to ensure the temperature has reached the parameters
of at least 3 minutes at 134c and stayed above 134c for the specified
period determined during penetration study.
Note a minimum of 3 minutes at 134c is required for unwrapped goods.
For wrapped, packed or pouched items, these measurements need to be
confirmed by a technician, known as penetration time and time at
temperature testing at validation.
Step 2
Circle and sign these parameters on the printout and attach to the
sterilisation log.
Step 3
Open the steriliser door to its maximum to allow contents to cool.
Step 4
Turn off electricity or as per manufacturer’s instructions.
Step 5
Wash hands with liquid soap and dry thoroughly with paper or single
use towel or put on clean, dry gloves. Use gloves specifically designed
for removing hot sterilising racks from the chamber to prevent staff
receiving burns.
Step 6
Visually examine packages to ensure that:

the load is dry

the packages are intact

The indicators have changed colour.
Any items that are dropped on the floor, torn, wet or have broken or
incomplete seals are contaminated and must be repackaged and
reprocessed.
Step 7
Take items from the sterilising chamber and place on a cooling rack on a
clean field until cool (or allow items to cool inside the chamber once
packages have been checked).
Step 8
Record details in the sterilisation log.
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4.7.5 Documentation of the Cycle
(Customise as appropriate)
Policy
A sterilisation log is maintained which contains details of:










date of cycle.
steriliser Identification (only if more than 1 steriliser in the practice).
load Number.
contents of the load.
identification of the person who prepared the load.
class 1 Chemical indicator change.
condition of the packs. (dry with seals and package integrity intact).
evidence of the process such as a print out or class 4,5 or 6 Chemical Indicator or
if a data download logger is used, sign off that it was viewed and is correct.
signature of the person releasing the load.
any comments or problems such as failed cycles and actions taken.
Procedure



the Loading section of the sterilisation log is completed and signed when the steriliser
is loaded.
the unloading section of the sterilisation log is completed and signed when the
steriliser is unloaded.
sterilisation log sheets are retained and filed <<insert the location for storage>>
according to the procedures for medical records.
Failed cycle
In the event of a failed cycle:
 document failed cycle with a brief summary of the problem in the sterilistion log.
 notify appropriate staff members.
 do not use items from the steriliser until the error is rectified.
 refer to the troubleshooting guide on the operating instructions.
 replace the packaging and re-process the instruments.
 if fault occurs again contact the service technician for advice and record any
actions in the Steriliser Maintenance Log Sheet.
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4.7.6 Monitoring the Sterilisation Process
(Customise as appropriate)
Policy
Monitoring is a programmed series of checks and challenges, repeated periodically, and
carried out according to a documented protocol, which demonstrates that the process being
studied is both reliable and repeatable.
If the temperature or pressure of the steam inside the autoclave is above or below what it
should be, the steam will not be able to condense and sterilisation will be unreliable. The
efficiency of the sterilisation process should therefore be checked on a regular basis
according to the manufacturer’s specifications or those documented in the current edition of
AS/NZS 4815.
Procedure
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Our practice follows these methods of monitoring:Test – Processed
Method
Class 1 chemical indicator
Frequency
A class 1 chemical indicator must be used for:
every wrapped item (external), or
every load, if unwrapped.
Test – Time, temperature and pressure
Method
Frequency
Time, temperature and pressure can be measured by using:
a steriliser with a print out facility, or
data logger/computer download, or
manually recording of temperature and pressure throughout the
cycle, or
Class 4, 5 or 6 chemical indicator (time and temperature only).
Every load
Test – Calibration
Method
By a qualified service technician
Frequency
6 – 12 monthly (or more frequently as per manufacturer’s
instructions)
Test – Validation
Method
See definition and process below
Frequency
12 monthly and as required
RACGP 4th edition Standards 5.3.3
4.7.7 Validation of the sterilisation processes
(Customise as appropriate)
Policy
“Validation” is a documented procedure for obtaining, recording and interpreting results
required to establish that the sterilisation protocols/procedures followed by our practice will
consistently yield sterile instruments and equipment, as exactly the same procedure is
followed for every part of each sterilisation process.
“Sterilisation” is more than simply putting loads through a steriliser. Successful sterilisation
to achieve and maintain sterility of equipment and instruments reliably and repeatedly is a
process which begins with pre-cleaning of equipment after use, cleaning of the instruments,
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drying, packaging, loading the chamber, the sterilisation cycle, unloading the chamber,
monitoring of each cycle, recording cycle details and monitoring in the log book, storage and
traceability of the sterilised equipment, detection of abnormalities in the process and
corrective appropriate action, and daily, weekly and annual steriliser maintenance.
Validation covers three activities, which are:
 installation qualification (‘commissioning’)
 operational qualification (‘commissioning’)
 performance qualification.
The validation process must be carried out by our practice upon installation and annually in
conjunction with a maintenance contractor. A qualified service technician must ensure that all
gauges and process recording equipment fitted to the steriliser are calibrated using
independent test equipment. The contractor must also document results of heat
distributionstudies on an empty chamber and conduct a penetration test using our practice’s
challenge pack.
Validation of the sterilisation processes must be completed as soon as possible after the
routine annual calibration and service, and immediately after any of the events listed below:



commissioning a new steriliser (a service technician should install the steriliser
according to manufacturer’s instructions and should then check the operation of the
machine)
significant changes are made to the existing steriliser, such as major repairs or recalibration, which could adversely affect the result of the sterilisation process
changes to any part of the sterilisation process, such as changes to the contents, packing
or packaging of the “challenge pack” or to loading details of the “challenge load”.
If validation of the sterilisation process is successful then any load subsequently processed
over the next twelve months can be treated as sterile. This is provided that:



all the validated documented sterilisation procedures continue to be followed exactly
the pack contents, packing, and packaging and chamber loading do not exceed the
parameters of the validated packs/loading
each cycle is monitored correctly and no changes are made to any part of the
sterilisation process, which could adversely affect it.
Procedure
Our practice follows this procedure when conducting validation:
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Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Review and perform your infection control policies and procedures
including:
 workflow issues
 cleaning of instruments
 pack contents, packing and packaging
 loading of the steriliser
 sterilisation cycle
 unloading the steriliser
 storage of sterile items
 maintenance of the steriliser.
Check that the procedures were successful in terms of performance and
reliability and sign-off each one using the validation methodology
checklist. Attach the validation methodology checklist to the validation
record.
Select the hardest to sterilise items (challenge pack) in terms of product or
pack density to create your challenge pack and record details on the
validation record.
At time of routine service, request the service person to:
 calibrate the machine
 conduct a heat distribution or “cold spots” study in an empty chamber
(usually performed only on installation, or available from the
manufacturer or otherwise determined by the sterilisation technician)
 obtain the penetration time using a thermocouple or data logger by
choosing the hardest to sterilise items in terms of product or pack
density to create your challenge pack
 undertake a time at temperature analysis to ensure the temperature is
maintained throughout the entire sterilisation phase.
 provide servicing/testing documentation detailing the outcome.
Where onsite technical support is not immediately available, please refer
to the current edition of the AS/NZS 4815.
Using the validation record template, record the following details:
 date of annual validation
 batch number and biological indicators
 cycle that is being used for validation
 temperature and time at which validation is being done
 attach your servicing/testing documentation to the validation record.
Select the items that you will include in the load and record details on the
validation record including the “challenge pack”.
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Step 7
Step 8
Step 9
Step 10
Step 11
Step 12
Step 13
Step 14
Label the biological indicators to reflect cycle as follows:
1st Cycle label one Indicator 1M (for the 1st Indicator placed in the 1st
cycle challenge pack in the middle of the pack) and the other 1C (for
the non packed Indicator placed on the tray nearest the coldest part of
the steriliser chamber)
2nd Cycle label one Indicator 2M (for the 2nd Indicator placed in the 2nd
cycle challenge pack in the middle of the pack) and the other 2C (for
the non packed Indicator placed on the tray nearest the coldest part of
the steriliser chamber)
rd
3 Cycle label one Indicator 3M (for the 3rd Indicator placed in the 3rd
cycle challenge pack in the middle of the pack) and the other 3C (for
the non packed Indicator placed on the tray nearest the coldest part of
the steriliser chamber)
the 7th Indicator can be labelled Z. This indicator is never sterilised and is
usually placed beside the steriliser whilst the three (3) consecutive
cycles are being run. This 7th indicator will prove that the batch of
indicators was active.
Place the biological indicators inside the challenge pack and in the coldest
spot of the chamber and outside of the steriliser. Record the location in the
test indicator diagram on your validation record.
Load the steriliser as documented above and draw or photograph details in
the loading diagram on your validation record.
Perform three consecutive, identical loads and cycles including the test
indicators as marked. With each load, unpack and repack the challenge
pack. All items for each load must be at room temperature.
Send the biological indicators for testing/incubation to the pathology
company or use an in-house incubator set at correct temperature for
incubation.
Document the findings and investigate any failures (a pass result is
100%).
Any load run subsequently and which does not exceed the parameters of
the validated load can be treated as a load not requiring biological test
indicators.
Attach this checklist to the validation record.
RACGP 4th edition Standards 5.3.3
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4.7.8 Maintenance of the steriliser
(Customise as appropriate)
Policy
It is critical that the steriliser is maintained by practice staff and service personnel, in
accordance with the steriliser manufacturer’s instructions and that routine servicing by
suitably qualified person occurs at least annually.
The maintenance procedures must be clearly documented, performed and recorded on an
ongoing basis (daily, weekly and monthly) by practice staff and service technicians. The
operating instructions are located <<insert location>>.
Procedure
Changing the water
Deionised or distilled water is used and the water reservoir is checked prior to use and
drained and refilled weekly
Cleaning the steriliser
Scale build up and corrosion in the chamber is regularly cleaned using a phosphoric acid
or citric acid solution or paste. Outlet drains are visually checked to ensure they are free
of debris and seals are visually checked for signs of wear and tear.
4.7.9 Servicing the steriliser
A maintenance contract for servicing of the steriliser is established with <<insert name of
organisation>>. The steriliser is serviced at least 12 monthly or more frequently if
required.
The servicing company details are: <<insert company name, contact person and
telephone contact details>>.
Validation of the sterilisation process
Performed at least annually or more frequently if required. Usually this is following the
service. Validation is undertaken, according to the validation protocol.
Documentation
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All maintenance and servicing is documented in the maintenance log. This includes
maintenance performed by staff such as changing the water, cleaning and checking the door
seal and outlet drain.Evidence of validation is documented and retained. The 3 validation
cycles are recorded in the sterilisation log. Documentation relating to the maintenance and
servicing of the sterilizer is kept <<insert location/s>>.
4.9
Storage of sterile items
(Customise as appropriate)
Policy
All sterile items, including those processed in the practice facility and those procured from
commercial suppliers, shall be stored and handled in a manner that maintains the sterility of
the packs and prevents contamination from any source.
Factors that influence shelf life are event-related (not time-related) and are dependent on
storage and handling conditions.
Procedure
Instruments in our practice are stored:






in a clean, dry and well ventilated area
in an area free from draughts
in an area where there is reduced chance of contamination from dust and water
with dust covers should items be stored for a long period of time
in a manner which allows stock rotation, e.g. place recently used items at the back and
take from the front
with the contents of the package clearly visible to reduce handling of instruments.
Instruments and items used for procedures in other locations such as aged care facilities and
home visits are transported to the facility in a separate rigid walled container with a lid
labelled sterile items. Care is taken to maintain the sterility of these while transporting to the
facility.
In our practice, sterile equipment is kept <<insert location>>.
RACGP 4thedition Standards 5.3.3
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4.10 Management of waste
(Customise as appropriate)
Policy
The RACGP Infection Control Standards for Office Based Practices outline policies and
procedures to assist our practice to safely manage waste. We are also aware of any relevant
local or State regulations that impact on our waste management.
Our waste policies include:
 use of Standard precautions when handling waste
 correct segregation of waste into three streams: “Clinical”, “Related” and “General”
 storage of waste
 disposal of waste
Effective and safe waste management is important for infection control and also to reduce the
impact on the environment and reduce costs.
All staff receive education regarding the management and handling of waste, appropriate to
their role, including the safe use and disposal of sharps.
These categories are defined as:


clinical waste has the potential to cause sharps injury, infection or public offence and
includes: discarded sharps, human tissues (but excluding hair, teeth, urine and faeces)
and materials or solutions containing free flowing or expressible blood. It also
includes related waste such as cytotoxic waste, pharmaceutical waste, chemical waste
and radioactive waste
general Waste is any waste that does not fall into the clinical or related category and
may include office waste, kitchen waste, urine, faeces, teeth, hair, nails, sanitary
napkins, tampons, disposable nappies, used tongue depressors, disposable vaginal
specula, cervical cytology spatulas and plastic cytology brushes, nonhazardous
pharmaceutical waste (e.g. out of date saline).
NB: General waste contaminated with blood or body substances (though not to such an
extent that it would be considered clinical waste, i.e. not contaminated with
‘expressible blood’) must be stored in out of reach or access to children.
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Procedure
All staff use appropriate PPE which always includes gloves as a minimum, when handling
waste. Clinical waste is removed by trained staff. Waste, either general or clinical, is not
compressed by hand.
Clinical waste includes sharps disposal containers and designated biohazard bins. These are
located in each area where clinical waste is generated. They are emptied <<insert
frequency>>.
Containers used for “non sharp” Clinical Waste in our practice:
 have a good sealing lid.
 hand free operation (e.g. wide open mouth, foot pedal or sensor operated)
 rigid walls
 should be lined with a plastic bag (preferably a yellow biohazard identified bag)
 have a biohazard sign affixed to the outside.
 are located away from the reach of children.
While awaiting collection non sharp clinical waste is double bagged using a biohazard
identified yellow bag and stored securely inside a locked yellow biohazard identified bin in an
area that is separate from clean stores and with restricted access.
Sharps are defined as anything that can penetrate the skin and some examples include:
needles, scalpels, stitch cutters, glass ampoules, sharp plastic items, punch biopsy equipment,
lancets, wire cytology brushes, razors, scissors and disposable surgical instruments.
Containers used for disposal of “sharp” clinical waste:
 comply with Australian standards
 are placed out of reach of children
 cannot be knocked over
 are located so that the neck is clearly visible to health professionals when disposing of
items
 have scalpel blade removers securely mounted to the walls
 are closed and replaced when the full indicator is reached.
While awaiting collection sharps containers are never reopened and are stored with the other
clinical waste for collection.
Related waste
 cytotoxic products are disposed of into the sharps containers.
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

pharmaceutical waste is disposed of in accordance with the state/ regulations. Our
practice uses the services of <<insert the name of the pharmacy or service>>.
chemical waste such as formalin need to be disposed of according to state/territory and
local government regulations and OH&S requirements.
This practice has a service agreement, with <<insert name of company>>, who are
contractors specifically licensed to dispose clinical waste through special burial or high
temperature incineration. The bins are collected every <<insert frequency of clinical waste
collection>>. <<Insert person’s name>> is delegated responsibility to ensure adequate stock
levels of clinical waste containers are maintained and collection schedules are timely.
Our practice considers recycling principles and the environmental impact when sorting
general waste. General waste must not be accessible to children particularly when
contaminated by blood or bodily fluids.
The sensitivity of information should also be considered when disposing of paper-based
materials.
RACGP 4th edition Standards 5.3.3
4.11
Sharps Management
(Customise as appropriate)
Policy
Our practice makes every attempt to minimise the risk of injury to both staff and patients, and
prevent the possible transmission of disease by discarded sharps.
Sharps represent the major cause of accidents involving potential exposure to blood-borne
diseases. All sharp items contaminated with blood and body fluids are regarded as a source of
potential infection. Safe handling and disposal of sharps is essential to protect the operator
and others from injury and possible transmission of disease. Sharps may be defined as any
object or device that could cause a penetrative injury.
Consideration is given to the purchase and use of devices that significantly reduce the risk of
sharps injury.
The staff member who generates or uses a sharp is responsible for the safe use and disposal of
that sharp. This responsibility cannot be delegated.
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The employer is responsible to ensure all staff are familiar with the practice’s policy and
procedure for the safe handling and disposal of sharps and staff are also familiar with the
actions to take in the event of a sharps injury.
Procedure
Sharps disposal containers are placed in all areas where sharps are generated. Where possible
they are located between hip and shoulder height. Sharps are placed into rigid-walled,
puncture-resistant yellow containers that meet the relevant Australian Standard. Containers
are not in a location accessible to children either when in use or when awaiting collection.
The following principles are taken into consideration:
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the person using the sharp is legally responsible for its safe disposal.
sharps must be disposed of immediately or at the end of the procedure whichever is
most appropriate.
sharps must be placed in a yellow puncture-resistant container bearing the black
biohazard symbol (AS 4031).
used sharps must not be carried about unnecessarily.
injection trays must be used to transport the needle and syringe to and from the
patient.
needles and syringes must be disposed of as one unit.
needles must not be recapped.
needles must not be bent or broken prior to disposal.
containers must not be overfilled as injuries can occur whilst trying to force the sharp
into an overfilled container – close container securely when at the fill line.
the lid must be sealed once the container is full. For push-on lids, use both hands and
apply pressure only to the edges of the lid.
sharps disposal units must be conveniently placed in all areas where sharps are
generated and should be mounted on a wall or on a bench to prevent spillage.
sharps containers must not be placed on the floor or in areas where unauthorised
access or injury to children can occur.
sharps containers must not be placed directly over other waste or linen receptacles
assistance must be obtained when taking blood or giving injections to an
uncooperative patient or to a child.
For removal and disposal of the sharps container, refer to the instructions detailed under
‘Waste Disposal’ above.
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This practice assumes an active role in reducing the opportunities for sharps injury by
purchasing safe equipment whenever such an option is available without compromising the
quality and safety of patient care. Examples include:
 self retracting single use lancets for blood glucose testing
 self retracting canula insertion devices and needleless. IV administration systems.
 vacuum blood collection tubes
 scalpel blade removal devices
 plastic ampoules
Our induction process includes information about the safe disposal of sharps and actions to
take in the event of a sharps injury.
RACGP 4thedition Standards 5.3.3
4.12 Transmissible and Notifiable Diseases
The following table outlines the required action to be taken by practice staff in the event of a
suspected or confirmed case of the listed diseases. All staff has been given adequate training
in how to respond to these cases.
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Disease
Acute Bacterial Conjunctivitis
Adenoviruses
Amoebiasis
Anthrax – cutaneous
Anthrax - pulmonary
Bronchiolitis
Chickenpox
Croup
Cytomegalovirus (CMV)
Ebola
Enteroviruses
Extended Spectrum Beta-Lactamase (ESBL)
Giardiasis
Hand, foot and mouth disease
Hepatitis A
Herpes simplex
Haemophilus influenza type B (HIB)
Impetigo
Influenza
Measles
Methicillin Resistant Staphylococcus Aureus
(MRSA)
Meningitis
Mumps
Parvovirus B19
Pediculosis
Pertussis
Pinworm
Respiratory Syncytial Virus (RSV)
Rotaviruses
Round worm
Ring worm
Rubella
Salmonellosis
Scabies
Shigellosis
Shingles
Slapped cheek disease
Staphylococcal infections
Streptococcus Group A
Sudden Acute Respiratory Distress Syndrome
(SARS)
Tuberculosis
Vancomycin Resistant Enterococci (VRE)
Varicella
Viral haemorrhagic fevers
Recommended
Precautions
Contact
Droplet
Contact
Contact
Airborne
Contact and droplet
Contact and airborne
Droplet
Contact
Airborne
Contact
Contact
Contact
Contact
Contact
Contact and droplet
Droplet
Contact
Contact and droplet
Contact and airborne
Contact
Droplet
Droplet
Droplet
Contact
Droplet
Contact
Contact and droplet
Contact
Contact
Contact
Droplet
Contact
Contact
Contact
Contact and droplet
Contact
Contact
Droplet
Contact and airborne
Airborne
Contact
Contact and airborne
Airborne
Reportable to State/Territory
Health Departments
Yes, if gonorrhoeal or
chlamydial
No
No
Yes
Yes
No
No
No
No
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes
Yes
No
No
Yes
No
No
No
No
No
Yes
Yes
No
Yes
No
No
No
No
Yes
Yes
No
No
Yes
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4.13 Standard Precautions
(Customise as appropriate)
Policy
Standard precautions apply to work practices that assume that all blood and body substances,
including respiratory droplet contamination, are potentially infectious.
The NHMRC recommends the use of personal protective equipment including heavy duty
protective gloves, gowns, plastic aprons, masks, eye protection or other protective barriers
when cleaning, performing procedures, dealing with spills or handling waste
Standard precautions are standard operating procedures that apply to the care and treatment of
all patients, regardless of their perceived or confirmed infectious status. Standard precautions
also apply to the handling of blood and other body fluids.
Standard precautions are work practices that are used consistently to achieve a basic level of
infection control in all health care settings and all situations.
Standard precautions are designed to protect both patients and staff, and comprise the
following measures:
 hand washing
 use of appropriate personal protective equipment (PPE) for example gloves, plastic
aprons and eyewear
 use of aseptic technique to reduce patient exposure to microorganisms
 safe management of sharps, blood and body fluid spills, linen and clinical waste
 routine environmental cleaning
 effective reprocessing of reusable equipment and instruments
 evironmental controls such as design and maintenance
Procedure
All staff involved in patient care or who may have contact with blood or body fluids are
required to understand and use standard precautions when they are likely to be in contact
with:
 blood
 other body fluids, secretions or excretions, except sweat (e.g. urine, faeces)
 non intact skin
 mucous membranes
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RACGP 4th edition Standards 5.3.3
4.14 Additional Precautions
(Customise as appropriate)
Policy
Additional precautions are used for patients known or suspected to be infected with highly
transmissible pathogens. Additional precautions are measures used in addition to standard
precautions when extra barriers are required to prevent transmission of specific infectious
diseases.
Our staff are educated in how to triage and apply additional precautions for patients known or
suspected to have a potential communicable disease.
Additional precautions require:
 ‘isolation’ of the infectious source to prevent transmission of the infectious agent to
susceptible people in the health care setting
 a means for alerting people entering an isolation area of the need to wear particular
items to prevent disease transmission.
There are three additional precaution categories based on routes of infection transmission in a
health care environment. These are:
 contact precautions
 droplet precautions
 airborne precautions.
Procedure
Additional precautions are used for patients known or suspected to be infected with highly
transmissible pathogens (e.g. influenza).
In general practice the main goal is minimising exposure to other patients and staff. This may
be achieved through:
 the use of PPE
 distancing techniques (one metre between patients in the waiting room, isolating the
patient in a separate room or their car)
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effective triage and appointment scheduling including putting these patients ahead of
others
hand hygiene
encouraging cough etiquette and respiratory hygiene
surface cleaning
avoid touching your nose & mouth
To help prevent the transmission of communicable diseases, our practice educates patients
through posters and information leaflets on appropriate respiratory etiquette, hand hygiene
and triaging influenza cases.
RACGP 4th edition Standards 5.3.3.
4.15 Personal Protective Equipment (PPE)
(Customise as appropriate)
Policy
Our practice has available Personal Protective Equipment (PPE) which includes heavy duty
protective gloves, gowns, plastic aprons, masks (surgical & P2), eye protection; or other
protective barriers in all cases where there is potential for contact with blood or body fluids
such as when cleaning, performing procedures, dealing with spills or handling waste and
when dealing with infectious diseases.
Procedure
All staff and patients have easy access to appropriate PPE. In areas where PPE is used there
are posters providing education on the appropriate application, removal and disposal of PPE
PPE is also used when handling chemicals such as cleaning products or Liquid Nitrogen.
Our practice ensures that all staff receive education, at induction and on an ongoing basis, as
to the appropriate use of various types of PPE, and where to access it. Staff training records
are kept <<insert location>>.
PPE includes:
 gloves (sterile, non sterile and standard rubber type).
 face masks including standard surgical and P2 masks.
 face and eye shields.
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gowns (long and short sleeved).
plastic aprons.
All staff understand and are competent in:
 determining the appropriate use and selecting the correct type of PPE for the
presenting situation.
 explaining the purpose of different PPE equipment.
 demonstrating the correct fitting and removal of PPE and the safe disposal of these
items.
PPE is located <<insert location>>. Maintenance and reordering of PPE is the responsibility
of <<insert staff member name>>.
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PPE
Appropriate use
Disposable
gloves
Disposable gloves should be used:
Sterile gloves
Heavy duty
gloves
Surgical Masks

when handling blood and body substances or when contact
with such is likely

when handling equipment or surfaces contaminated with such
substances

during contact with non-intact skin

during venipuncture – although needlestick injury may still
occur, the presence of the glove layer could reduce the volume
of any inoculum.
Sterile gloves should be used:

during any surgical procedure involving penetration of the skin
or mucous membrane and/or other tissue

when venipuncture is performed for the purpose of collecting
blood for culture.
Heavy duty gloves should be used:

during general cleaning and disinfection

during instrument processing

during cleaning blood or body fluid and other substance spills.
Surgical Masks can be used:

during procedures or activities that might result in splashing
and the generation of droplets of blood, body substances or
bone fragments

When there is a risk of droplet transmission of disease.

To protect unimmunised staff and patients

Worn by the patient to prevent the spread of disease (suspected
or known)
P2 or N95 Masks Worn by staff when there is a risk of airborne transmission of disease
(suspected or known) Tuberculosis and pandemic influenza.
(Particulate
filter masks)
Protective
eyewear
Protective eyewear should be used to prevent splashing or spraying of
blood and body fluids into the wearers eyes such as during surgical
procedures, venipuncture, or cleaning of spills, contaminated areas or
instruments.
Worn by staff when there is a risk of airborne/droplet transmission of
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disease (suspected or known).
Gowns and
plastic aprons
Gowns and plastic aprons should be used when there is a risk of
contamination of wearer’s clothing or skin with blood and body
substances such as during surgical procedures, venipuncture, or
cleaning of spills, contaminated areas or instrument processing.
Worn by staff when there is a risk of airborne/droplet transmission of
disease (suspected or known).
Sterile gowns
Sterile gowns should be used during procedures that require a sterile
field.
All staff use appropriate PPE when undertaking any of the following procedures:
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any examinations requiring contact with mucous membranes.
cleaning or dressing wounds, taking down bandages.
cleaning up after procedures.
preparing instruments and equipment for sterilisation.
assisting with or performing procedures.
cleaning of contaminated surfaces.
cleaning spills of blood & body fluids.
using chemicals.
taking blood.
handling all pathology specimens before they are bagged.
controlling bleeding.
RACGP 4th edition Standards 5.3.3
4.16 Laundry
(Customise as appropriate)
Policy
All staff members at our practice have received education regarding the management of soiled
linen, including when to change linen, the use of appropriate precautions during handling, the
washing, drying and storage of linen.
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Procedure
Linen needs to be changed if:
 a patient requires the use of contact precautions, (e.g. known or suspected of having
CAMRSA, scabies or lice)
 blood or body fluid has been spilt on the linen
 it is visibly soiled.
 before an operative procedure.
When changing linen:
 staff use PPE and standard precautions as required
 care is taken to ensure sharps are not caught up in the linen
Clean linen is located in a clean, dry dust free location away from dirty linen and items. In our
practice, clean linen is stored <<insert location of clean linen>>.
Option 1: (select if you purchase all disposable linen for your practice)
This practice uses only disposable linen on all examination couches and patient treatment
areas.
Linen is changed regularly and, provided it does not contain expressible blood or body fluid,
it is disposed of into the normal domestic rubbish. Any linen that is contaminated with
expressible blood or body fluid is disposed of immediately into the clinical infectious waste
bin.
Option 2: (Select if your practice wash/launder and reuse your linen and delete Option 1
and 3)
Used linen is stored in a covered, lined container which is located away from clean items in
the (*insert location) before laundering. Any linen that is contaminated with blood or body
fluids is collected in a plastic bag before being placed in the used linen receptacle and is
rinsed in cold water with oxygenated stain removal at the earliest opportunity
All linen is transported in a leak proof container. A separate clean, container or basket is
used to return laundered linen to the practice. Linen is washed in a washing machine on a
hot or cold cycle using activated oxygen based laundry detergent and dried in the dryer.
Option 3:( Select if you use a laundering service to wash and reuse your linen and delete
Option 1 and 2)
The laundering is contracted out to a commercial laundry service. The laundering service
used is <<insert name of the company you use>>. A copy of our agreement is available
from <<insert location kept>>.
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RACGP 4th edition Standards 5.3.3
4.17 Safe handling of pathology specimens
(Customise as appropriate)
Procedure
The following process is followed when handling pathology specimens:
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label and name containers before use to avoid the need for extensive handling after the
specimen has been collected.
after collection of blood and body substances these should be placed in the appropriate
specimen container, as specified by the testing laboratory.
wipe the container clean to remove any visible soiling and check specimen is correctly
identified.
securely seal to prevent any leakage during transport.
place the container upright in a waterproof bag or container.
take care to avoid contamination of pathology slips by keeping them separate from the
clinical specimens.
for transport between institutions and interstate, pack the primary specimen,
surrounded by sufficient material to absorb its contents, in a sealable inner container
and provide a sealable outer container of waterproof, robust material. Label in accord
with postal and other transport regulations. Keep cool if necessary.
RACGP 4th edition Standards 5.3.3
4.18 Environmental Cleaning Service
(Customise as appropriate)
Policy
All areas of our practice environment are visibly clean.
Regular cleaning of work areas is necessary because dust, soil and microbes on surfaces can
transmit infection. Cleaning of our practice clinical and non clinical areas must be regular and
scrupulous.
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We have a cleaning policy that sets out a schedule and responsibilities for cleaning all areas of
the practice in accordance with the requirements outlines in the RACGP Infection control
standards for office based practices (4th edition).
We have appointed one member of staff with primary responsibility for the development and
consistent implementation of our infection control systems and procedures which includes
environmental cleaning.
Specific areas of responsibility may be delegated to nominated members of the practice
team and these particular responsibilities should be documented in the relevant position
descriptions. The practice team member with delegated responsibility for environmental
cleaning can describe the process for the routine cleaning of all areas of the practice and
can provide documentation on the practice’s cleaning policy.
A good neutral detergent can be used for most of the cleaning requirements in a health care
setting, and this includes floors, walls, toilets and other surfaces. The use of disinfectants is
discouraged because they are expensive, often toxic and require contact times to be effective.
All work surfaces are made of smooth, non-porous material without cracks or crevices to
allow for efficient cleaning. Any gross soiling or body substance spills must be cleaned as
soon as possible. Sinks and wash basins must be either sealed to the wall or sufficiently far
from the wall to allow cleaning of all surfaces.
Damp dusting and wet mopping is used in the cleaning of the environment. Dry dusting and
sweeping will disperse dust and bacteria into the air and then resettle. It is potentially
hazardous and inefficient, and must be avoided in patient treatment or food preparation areas.
All cleaning equipment is stored in a clean and dry condition, in an area not accessible to the
public.
Our practice has a cleaning schedule with procedures for cleaning clinical and non-clinical
areas of our practice.
All cleaning staff must receive training in WH&S issues appropriate to general practice and
the immunisation status of all cleaning staff is documented.
All staff involved in cleaning receives ongoing education in our infection control policies
including Hand Hygiene and the correct use of Personal Protective Equipment (PPE) and
Waste management.
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Procedure
<<Insert name>> has the delegated responsibility for the development and consistent
implementation of our environmental cleaning processes. This includes education of staff
and following up any issues with the quality of environmental cleaning.
Our cleaning schedule below describes the frequency of cleaning, products to use and
person responsible for cleaning specific clinical and non clinical areas of the practice.
Where appropriate we have documented evidence of cleaning activity.
Additional and specific cleaning may be required in areas where patients known or
suspected to be infected with highly transmissible agents (e.g. influenza) have been.
Option 1: (Select if your practice is cleaned by staff and contract cleaners then delete all
other options)
Practice staff and contract cleaners are responsible for cleaning the premises as specified
in the documented cleaning register.
Practice staff undertake daily cleaning and the contract cleaners provide general cleaning
in all areas of the Practice on a <<insert frequency>> basis.
An annual contract with <<insert contract cleaners name>> is negotiated and reviewed
every <<insert review date>>. Evidence of cleaning and cleaning procedures is kept
<<insert location>>.
Option 2. (Select if all cleaning is performed by practice staff. Then delete all other
options)
Practice staff members are responsible for cleaning the premises. Documented cleaning
procedures and evidence of cleaning are kept <<insert location>>.
Option 3 (select if cleaning is only performed by a contracted cleaning service. Then
delete all other options)
An external cleaning service <<insert contract cleaners name>> is responsible for
cleaning the premises as specified in the attached cleaning guide.
This service is contracted to provide general cleaning in all areas of the Practice on a
daily basis (Mon – Fri).
An annual contract is negotiated and reviewed every <<insert review date>>.
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The cleaning service operates after 5pm. Spills that occur during normal consulting
hours are the responsibility of <<insert person’s name>>.
Cleaning staff should adhere to the following principles when cleaning:
 don personal protective equipment (PPE) such as gloves and a waterproof apron
 make up water and detergent solution each day
 use clean dry cloths and mops
 wash and dry all surfaces
 promptly dispose of used cleaning solution in the dirty utility area, not in hand basins
or clinical sinks
 wash and dry buckets, cloths, mops and PPE after use
 wash hands when each task is completed.
Areas which are only cleaned/ managed by appropriately trained practice staff are:
 spillage of blood or body fluids
 medical instruments or items for re-use are cleaned according to the procedure for
cleaning instruments and re-usable items.
 treatment room benches and trolleys
 consulting room benches containing medical equipment
 infectious waste and sharps containers
All practice staff responsible for cleaning have been appropriately immunised as
documented in their staff records. Should cleaning not conform to the expectations of
staff it should be reported to the <<insert designated environmental cleaning person>>.
The designated leader also conducts routine audits to ensure a high standard of cleaning.
Audits are done every <<insert frequency>> or more frequently as required, using items
as defined in the cleaning contract.
Safety data sheets of cleaning solutions, disinfectants etc are kept on file in case of a
medical emergency.
RACGP 4thedition Standards 5.3.3
Routine Cleaning Guide
Surface
Treatment room benches and
Method and cleaning
agents to be used
Wash with hot water and
Frequency
Nightly and more
Cleaner
Responsible
Authorised
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trolleys
detergent. Dry thoroughly
often if required
practice staff
Benches/drawers containing
medical Items
Wash with hot water and
detergent. Dry thoroughly
Weekly and more
often if required
Authorised
practice staff
Re-usable medical items and
instruments
Refer to procedure in
Section 4
As required
Authorised
practice staff
Benches and tables in kitchen
Wash with hot water and
detergent
Nightly
Sinks, hand basins and toilets
Hot water & detergent.
An abrasive cream cleanser
may be a useful stain
remover
Daily
Hard floors - Treatment
Room
Vacuum and wet mop with
hot water and detergent
Daily
Hard floors - Other areas
Vacuum and wet mop with
hot water and detergent
Daily - weekly
depending on use
Carpeted areas
Vacuum
Daily – weekly
depending on use
6 –12 monthly
Steam Cleaned
Office desks, benches and
furniture
Damp mop with hot water
and detergent / Vacuum
Weekly
Examination couches
Hot water and detergent
Daily
Toys
Dishwasher / Hot water and
detergent
Daily - Weekly
depending on use
Waiting Room furniture
Hot water and detergent/
Vacuum
Daily
Curtains - Cubicle
Machine hot wash
3 monthly
Windows and window
furnishings
Dry clean / Vacuum
Annually
Walls and ceilings
Hot water and detergent
Annually
Storerooms
Hot water and detergent
3 monthly
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5
Practice Management
5.1
Access & Parking
(Customise as appropriate)
Policy
The GPs and staff
 recognise that access to the practice facilities is important to our patients.
 make all reasonable efforts to facilitate physical access to the premises and
services offered.
 are committed to considering how best to meet the needs of our patients with
physical disabilities or other special needs.
Where possible wheelchair access, suitable parking and pictorial signage is provided to
assist patients with a physical or intellectual disability.
Where physical access is limited to the practice or where physically attending the practice
could result in an adverse outcome for the patient the practice provides off site or home
visits.
Car parking facilities are available within a reasonable distance from the practice for
staff, visitors and patients and where possible there are designated spots for disabled
drivers.
Sufficient signs are provided externally and internally to assist Staff, visitors and patients
in accessing the practice facilities.
Procedure
This practice provides physical access to patients, visitors and staff via the main entrance.
Our practice has a height adjustable examination couch located in <<insert location>>
to assist in the care of patients with a disability, and to reduce the risk of patients injuring
themselves when getting on or off the examination couch or staff when assisting patients.
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Doorways and walkways are to be kept free of clutter, boxes etc. to ensure a clear
pathway for all persons and in an emergency
Prominent signs at the front of the site:
 allow the public to easily locate the practice and the parking facilities from the
street.
 display the practice name, address, hours open, telephone numbers (work & after
hours).
(Please select correct option)
Option 1
Access for patients with disabilities.
 wheelchair access is provided to reception, toilets and consulting rooms.
 the practice has installed ramps and railings as required to assist patients with
disabilities
 designated disabled parking is provided in close proximity to the entrance
 (list additional measures, ie. wheelchair lift for stairs)
Option 2
As our practice has limited access to all facilities and services, home or other visits are
available for patients with disabilities or that may be otherwise unable to access a
practice service or facility.
RACGP 4th edition Standards 5.1.3 & 5.1.1
5.2
Appointments
(Customise as appropriate)
Policy
Our patient scheduling system is flexible enough to accommodate patients with urgent,
non-urgent, complex and planned chronic care, and preventative needs.
Our GPs and other members of the clinical team are consulted about the length and
scheduling of appointments. Patients are encouraged to book longer appointments for
multiple conditions, concerns or family members. Our standard consultation length aims
to provide adequate time for GPs to facilitate high quality care.
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Patients can request to see their preferred doctor or member of the health team. If a
patient is unable to see their preferred GP, they are advised about the availability of other
clinical staff and offered an appointment to see them. The urgency of the patient’s
condition is always assessed before booking an appointment with their preferred GP at a
later time.
Where possible information is provided in advance about the cost of healthcare and the
potential for out of pocket expenses.
If a patient presents at the practice with urgent medical needs, practice staff will respond
with appropriate action in relation to the patient’s condition. The practice makes every
effort to accommodate patients with urgent needs and all staff are trained in how to
respond to medical emergencies. A triage guide is available at the reception area to assist
non-clinical team members.
Procedure
(Please select the appropriate option)
Option 1 Appointment Based Booking System
In our practice, we use a pre-booked appointment system. A standard consultation is
booked for <<insert standard booking length>>. Patients can and are encouraged to
request longer consultations if necessary.
We accommodate urgent medical cases by: (customise as appropriate)
 Leaving vacant appointments throughout the day
 Having a designated GP to deal with urgent cases
 Employing the assistance of a nurse for triage procedures
All patients are asked at the time of requesting an appointment if the matter is urgent. In
urgent medical situations, practice staff follow the triage guide located <<insert location
of triage guide>>. All urgent medical situations are documented by practice staff in the
patient file and include details of:



The actions of practice staff
The presentation state of the patient
The names of any other staff or person involved in assisting with the emergency
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To provide continuity of care, all patients are asked who their preferred GP is or check
their record for previous appointments. If they are unable to see their regular GP on that
day, they are offered alternative appointments or other GPs within the practice.
If excessive wait times exist, practice staff make an effort to advise patients before
attending for their appointment.
Appointments made for patients required to attend a recall or periodic medical review
appointments are flagged and it is imperative the no shows are contacted and another
appointment re-scheduled.
Option 2 Informal Appointment System
Our practice uses an informal appointment system where patients are seen on a first
come, first serve basis.
When a patient requests an appointment, they are asked whether a longer consultation
will be required. Standard consultation times are <<insert standard consultation time>>.
We accommodate all medical emergencies as they are presented. Practice staff follow the
triage guide located <<insert location of triage guide>>. All urgent medical situations
are documented by practice staff in the patient file and include details of:



The actions of practice staff
The presentation state of the patient
The names of any other staff or person involved in assisting with the emergency
Patients are advised when presenting at the practice if there are excessive waiting times
and are encouraged to come back at a later time.
Patients are able to request their preferred GP or practice staff will check their
appointment history in an attempt to maintain continuity of care. If the patients preferred
GP is unavailable, the patient is offered an alternative GP (where possible).
Appointments made for patients required to attend a recall or periodic medical review
appointments are flagged and it is imperative that no shows are contacted and another
appointment re-scheduled.
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Procedure for making an appointment- Formal System
(Delete if not applicable)
Determine if the appointment is
urgent.
YES
Refer to the
triage guide.
NO
Determine if the patient is new or a
regular patient of the practice.
Regular
Patient
New
Patient
Provide the new patient
with as much
information about the
practice as possible
including any costs for
treatment,
arrangements for
parking and request
any specific documents
or information to bring
to their 1st visit.
Identify the patient using 3 approved
patient identifiers. Ask for the
patient’s preferred GP, time and date
for the appointment. If not available,
offer alternative time, date or GP.
Make a record of the patients appointment in the booking system under the
allocated time slot. Make any relevant notes associated with the appointment,
for example, worker’s compensation, etc.
*NB: If the patient indicates that the appointment is for the follow up of results, highlight
the appointment for the GP.
Procedure for making an appointment- Informal System
(Delete if not applicable)

When a patient requests an appointment, determine the urgency of the
appointment. If the appointment is urgent, follow the procedure in the triage
manual.
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




If the appointment is not urgent, determine if the patient is a new patient or a
regular patient of the practice.
If the patient is new, ask them to complete a new patient form. Enter their details
in the database and allocate them the next available timeslot. Since they are a new
patient, it’s best to allocate a slightly longer appointment time to allow a proper
medical history to be taken by the GP.
If the patient is a regular of the practice, ask the patient to confirm at least 3
approved patient identifiers. Do not volunteer this information to the patient but
ask them to state them.
Log the patient in the appointment system.
If there are excessive waiting times, inform the patient of their expected wait time
and invite them to come back at a later time.
Cancellations & Missed appointments
Policy
If appointments have been made for the follow up of test results, these are flagged in the
appointment system.
Patients who do no attend appointments are contacted, either by telephone or a letter sent
via registered post, and reminded of their appointment. Missed appointments for the
follow up of results are of crucial importance and are always followed up by practice
staff.
<<Delete if not applicable>>
Patient who do no attend appointments and fail to provide the practice with sufficient
notice will be charged a fee. Our policy for missed or cancelled appointments including
any associated fees, are outline din our Practice Information Sheet and a sign displayed
prominently in the waiting area.
RACGP 4th edition Standards 1.1.1, 3.1.4, 1.5.1, 1.2.4, 2.1.3, 1.5.3
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5.3
Home Visits
(Customise as appropriate)
Policy
Doctors and other practice staff make visits to regular patients of our practice where it is safe
and reasonable. These visits may be to patients in their homes, residential aged care facility,
residential care facility, or hospital both within and outside normal opening hours, where such
visits are deemed safe.
All patients are made aware that home visits or a suitable care alternative, are available both
within and outside normal opening hours via <<insert method used to notify patients>>.
Regular patients who meet the eligibility criteria are offered home visits.
For regular patients whose circumstances are deemed not safe and reasonable, e.g. the patient
is located too far away for a home or other visit, the practice ensures that there is an alternate
system of care that these patients can access.
There are arrangements to exchange clinical details about patient care for doctors who
perform home and other visits on behalf of the patient’s regular doctor and the care provided
is documented in the patient’s medical records.
Home and other visits are provided by appropriately qualified health professionals who
have received information and advice about safety and security when conducting home
visits.
Any anticipated costs associated with home visits or alternative care systems are discussed
with the patient.
Procedure
A patient can arrange for a home visit if the criteria below are met:




regular patients of this practice
live within a <<Insert km radius of the practice>>.
where it is deemed by the GP to be safe and reasonable
the patient has provided a phone number that you have called them back on
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
patient has the type of problem that necessitates a home visit such as:
 acute illness
 immobile
 elderly
 have no means of transport
 unable to access the practice facilities due to disability
 <<Insert your practice requirements here>>
If the patient at the time of request indicates that the matter is urgent, refer to the triage
protocol and list of urgent conditions for appropriate action. When in doubt, ask to put the
caller on hold and refer to the patient’s doctor for advice.
Our doctors home visit schedules are recorded in <<insert method of record>>.
Patients can request home visits however the final decision rests with the treating GP. Practice
staff are not to book home or other visits without consulting the GP.
When another health professional is performing home or other visits on behalf of GP at our
practice, arrangements are in place to ensure timely exchange of clinical information.
All visits provided within or outside normal opening hours are documented in the patient’s
medical records. If information is held about the patient in different records (for example,
residential aged care facility) there must be a record made for every consultation in each
system indicating where the clinical notes for the consultation are recorded to ensure patient
health information is available when required.
All staff undertaking home visits are given information and advice about protecting their
safety.
Where it is unsafe or unreasonable to provide a patient with care at home or in another
location outside the practice, patients are advised of alternative arrangements. <<Insert
the alternative system of care for patients of the practice>>. This advice is documented
in the patient health record along with evidence of the subsequent care provided.
RACGP 4th edition Standards 1.1.3, 1.7.1, 1.1.4, 1.2.4
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5.4
Telephone
(Customise as appropriate)
Policy
Our practice allows patients to obtain timely advice or information about their clinical
care via the telephone.
Staff members are mindful of confidentiality and respect the patient’s right to privacy.
Patient names are not openly stated over the telephone within earshot of other patients or
visitors. This practice prides itself on the high calibre of customer service we provide,
especially in the area of patient security, confidentiality, and right to privacy, dignity and
respect.
It is important for patients telephoning our practice to have the urgency of their needs
determined promptly. Staff should try to obtain adequate information from the patient to
assess whether the call is an emergency before placing the call on hold. Staff members
have been trained initially, and on an ongoing basis, to recognise urgent medical matters
and the procedures for obtaining urgent medical attention. Reception staff members have
been informed of when to put telephone calls through to the nursing and medical staff for
clarification.
Patient messages taken for subsequent follow-up by a doctor or other clinical staff are
documented for their attention and action, or in their absence to the designated person
who is responsible for that absent team members workload. Staff inserts the details of all
calls and telephone conversations assessed to be significant in a telephone call log.
The doctor needs to determine if advice can be given on the phone or if a face to face
consultation is necessary, being mindful of clinical safety and patient confidentiality.
Patients are advised if a fee will be incurred for phone advice. Non medical Staff does
not give treatment or advice over the telephone. The release of test results over the phone
by non-clinical staff is discouraged and can only be done under strict doctor instructions.
Before results are given over the telephone, all patients are identified using 3 approved
patient identifiers.
<<Delete as appropriate>>
<All practice staff are familiar with each GPs policy for returning telephone calls> OR
<A copy of each doctors telephone policy preferences if kept (insert location)> OR <Our
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practice uses a uniform telephone for all GPs. The practice policy for returning phone
calls to patients is (insert policy)>.
Staff do not give out details of patients who have consultations here nor any other
identifying or accounts information, except as deemed necessary by government
legislation or for health insurance funds.
A comprehensive phone answering message is maintained and activated to advise
patients of how to access medical care outside normal opening hours. This includes
advising patients to call 000 if it is an emergency. << If available, the practice ‘on hold’
call message advises patients to call 000 in the event of an emergency>>.
Staff are aware of alternative modes of communication that may be used by patients with
a disability or special needs including the Translating and Interpreter Service (TIS) and
the National Relay Service.
Important or clinically significant communications with or about patients are noted in the
patients health record.
Procedure
All telephone calls should be answered by a member if the practice team using an
approved/accepted greeting.
All calls are immediately assessed for their level of urgency by asking ‘is it urgent?’.
Calls which are to be placed on hold are firstly asked if this is acceptable and sufficient
time allowed for the caller to respond.
If the call is urgent, the practice staff member will refer to the appropriate action from the
triage guide or alert a member of the clinical care team immediately.
Telephone calls from patients which are not urgent are directed according to the GPs
telephone policy. Whenever messages are taken, they are recorded in <<insert
location/method>> and include details of the patient name, time/date of the call, and
nature of the call, any important facts and a return contact number. All messages must be
returned within a timely fashion or by the end of the day.
Sensitivity is paid to the privacy and security of patient health information and patient
details are not mentioned within earshot of other patients. Patients are identified using 3
approved patient identifiers before any personal information is discussed.
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Alternative modes of communication are available for patients with specific needs, for
example, TIS for patients with non-English speaking needs.
RACGP 4thedition Standards 1.1.1, 1.1.2, 1.1.4, 1.2.3, 5.1.2, 4.2.2
5.5
Electronic Communication
(Customise as appropriate)
Policy
Patients are able to obtain advice or information related to their care or appointment
reminders by electronic means, where the doctor determines that a face-to-face
consultation is unnecessary. Electronic communication includes: email, fax, and SMS.
Practice staff and doctors determine how they communicate electronically with patients,
both receiving and sending messages. All significant electronic contact with patients is
recorded in the patient health records.
Patients are advised through the Practice Information Sheet (PIS) of the practice policy
on electronic communications including:
 Seeking permission or consent from patients
 The possibility for electronic communications and information to be
compromised
 Notification of any costs involved
 The frequency of which emails are read by a member of practice staff
When an email message is sent or received in the course of a person's duties, that message is a
business communication and therefore constitutes an official record.
Employees should be aware that electronic communications could, depending on the
technology, be forwarded, intercepted, printed and stored by others. Electronic mail is the
equivalent of a post card. In regards to this, health information given in electronic
communications should be limited and discussed in more general terms. Patients should be
advised that information may be compromised.
Wherever possible, the practice should ensure secure encryption of emails is taking place.
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The practice uses an email disclaimer notice on outgoing emails that are affiliated with the
practice. The following disclaimer is used on all emails sent from this practice:
<<Insert message here>>)
(Delete if not applicable)
The Practice Website
Our practice has a website to communicate to patients important information about our
practice.
It is the responsibility of <<insert person responsible>> to update the practice website on a
<<insert frequency>> basis.
The practice website can be accessed using the following link <<insert link>>
The website is continually monitored to ensure it is kept current and up to date. It contains
the minimum information required on the practice information sheet. Any changes to the
practice information sheet are also reflected on the website.
If it contains any advertising the practice should include a disclaimer that the practice
does not endorse any advertised services or products. Advertising must comply with the
MBA Code of Conduct on advertising available at: http://goodmedicalpractice.org.au/.
RACGP 4thedition Standards 1.1.2 & 1.2.1, 4.2.2
5.6
Medical Emergencies & Urgent Queries
(Customise as appropriate)
Policy
This practice classifies patients seeking medical consultations, according to their priority
of need. Our triage system ensures that clinical care is provided to patients with urgent
medical problems as a priority.
Patients telephoning the practice have the urgency of their needs determined promptly.
Where possible, our phone on-hold message includes a recommendation to call 000 if the
matter is an emergency. Staff members know and use the triage process, a copy of which
is accessible at reception.
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Administrative staff and members of the clinical team have the skills and knowledge to
assess the urgency of the need for care and can describe our procedures for dealing with
urgent medical matters, including when the practice is fully booked.
Our induction process includes an orientation to our triage system and staff members are
given training in its effective use and are encouraged to regularly update CPR and other
first aid skills.
The doctors and staff provide appropriate care and privacy for patients and others in
distress.
We have provisions for doctors to be contacted after hours for life threatening or urgent
matters and/or results.
Procedure
Staff members receive regular training and update’s in CPR, appropriate for their duties,
at least every 3 years.
All Staff members receive information at induction and on an ongoing basis about our
triage guidelines and protocols for medical emergencies. Documentation of training is
retained in the individual staff training record.
Whenever patients contact the practice, their level of urgency for medical attention is
assessed by practice staff in accordance with the practice triage procedure.
A log book or computer entry is used to record all significant telephone conversations or
actions including medical emergencies and urgent queries.
The log records:






the name and contact phone number of the patient/caller
the date and time of the call
the urgent or non urgent nature of the call
important facts concerning the patient’s condition
the advice or information received from the doctor
details of any follow up appointments
A triage flowchart and triage manual are located <<insert location>>.
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RACGP 4th edition Standards 1.1.1
5.7
After Hours Service
(Customise as appropriate)
Policy
This practice ensures reasonable arrangements for medical care, including the follow up
of seriously abnormal and life threatening pathology results for our patients, both within
and outside our normal opening hours.
The arrangements for medical care outside normal opening hours, how to access this
care and the possibility of out of pocket costs, is communicated clearly to patients of this
practice. Feedback about the quality and timeliness of after hours care provided to our
patients by a deputising service is also obtained. Patient satisfaction with our after hours
service is regularly evaluated and improvements implemented if necessary.
Our practice provides after hours care through <delete as appropriate>>:
 Our practice GPs provide their own care for patients outside normal opening
hours either individually or through a roster.
 Formal arrangements for cooperative care outside the normal opening hours of
our practice through a cooperatives of one or more local practices
 Formal arrangements exist with an accredited medical deputising service
 Formal arrangements exist with an appropriately accredited local hospital or an
after hours facility.
<<Remove if care is provided by practice GPs>>
<<The practice has a formal written arrangement with this provider of after hour’s care
that outlines how it receives information about any care provided to their patients, and
how the GP providing the care can contact the practice for clarification or help regarding
background information relating to that patient, especially in an emergency.>>
Our patient health records contain reports or notes pertaining to consultations occurring
outside the normal opening hours for care.
Our practice has provisions enabling designated providers of after hours care or
pathology providers to contact a patients doctor, or in that persons absence, the person
who is caring for that absent team members patients.
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Procedure
Our normal opening hours are <<insert your opening hours here>>.
Advice to our patients on how to access after hours care, including the potential for out of
pocket expenses is available:<<delete those not applicable to your practice>>



in the practice information brochure
on a sign visible from outside the practice
practice website
Outside of normal hours the practice has a comprehensive message on the answering
machine, call diversion or paging system via our main telephone number. This message
includes recommending patients call 000 if the matter is an emergency. This is
maintained for all incoming calls when this practice is closed.
The patient feedback tool contains questions concerning adequate information being
given to patients about after hour’s services. The results of patient feedback are
evaluated and improvements implemented if required.
In the event that the practice doctors need to be contacted, we have an agreement
established with the following organisations:
 <<please list the organisations which you have arrangements with>>
Contact details for the GPs or their nominated replacements have been provided to these
organisations and it has been outlined in what situations they are to contact the GPs.
Any correspondence or notification received about after hours care provided to a patient
is documented in their medical record.
RACGP 4thedition Standards 1.1.1, 1.1.4, 1.2.4, 1.5.2, 1.2.1, 1.7.1, 2.1.2
5.8
Practice Meetings
(Customise as appropriate)
Policy
Regular discussions where all staff are encouraged to have input are important in building a
high performing team. We aim to cultivate a just, open and supportive culture where
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individual accountability and integrity is preserved, but there is a whole-of- team approach to
the quality of patient care.
(Select the most appropriate option)
Option 1
Practice meetings are conducted on a <<insert frequency>> basis or more frequently as
required to facilitate the exchange of practice news, other general administration and
protocol issues, complaints and to discuss risk management issues arising out of the
practice. Matters pertaining to clinical care may be discussed at these meeting if
appropriate, or at the practices clinical meetings.
Urgent daily notices or other general items are communicated to staff via <<insert method,
for example staff noticeboard, staff memo or distribution email>>.
Option 2
Due to the small nature of our practice, formal staff meetings or practice meetings do not take
place. Instead our practice communicates important issues via informal discussions held on a
daily basis during normal work hours. Important communications are detailed as a record in
the ‘Communications Book’.
Procedure
Staff meetings
It is important that all members of the practice team have the opportunity to discuss
administrative issues with the practice directors and/or owners when necessary. All staff are
expected to attend and contribute to the staff meeting.
Staff meetings are held <<insert frequency>> and minutes are recorded. Items for the
agenda may be submitted to the Practice Manager up to one week prior to the scheduled
meeting. All meeting minutes are kept <<insert location>>.
Administrative and WH&S practices are regularly reviewed at these meetings. Staff
members are given the opportunity to discuss administrative matters with the doctor(s)
and/or practice manager when necessary.
Discussion and suggestions for improvements to patient safety, policies or procedures
associated with risk management, is a standing item on our practice meeting agenda.
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Practice discussions about near misses or slips or lapses, with the intention of identifying
what went wrong and how to reduce the likelihood of it happening again, are also
included in practice and clinical meetings, where appropriate.
The decisions made at staff meetings should be documented along with the person responsible
for implementing the related action.
<<Delete if not applicable>>
The Communication Book is located <<insert location>> and all staff are able to access it to
read or make important notes regarding practice issues.
It is the responsibility of <<insert person responsible>> to ensure the communication book
is completed when necessary and viewed by all staff on a regular basis.
Clinical Meetings
Good communication between members of the clinical team is important for ensuring a
consistent approach to clinical care. Doctors and clinical staff, such as nurses and in
house allied health, meet face to face at least quarterly, to discuss clinical matters. In
between meetings, a communication book and emails are used to consider and
communicate clinical issues.
<<Insert person responsible for clinical improvement>> is responsible for leading the
clinical improvement and is the chair of the meetings. Practice protocols, near misses or latest
literature may be discussed. The meetings are recorded on the practice meeting schedule to
ensure staff can arrange to attend.
There is also a standing discussion item about clinical issues, support systems, new
guidelines and evidence. This includes a review of patient information brochures used for
preventative activities and to support management or treatment choices, to ensure they
are of appropriate quality and all members of the team are giving consistent information.
Clinical issues, updates, case studies and reports of Continuous Quality Improvement (CQI)
activities, complaints and incident reviews are presented, discussed and action taken as
required helping improve processes and patient outcomes.
Drug representatives may from time to time arrange a lunch or breakfast meeting, providing a
specialist to speak on a particular topic.
RACGP 4th edition Standards 1.4.1, 3.1.2, 4.1.1
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5.9
Patient Rights
(Customise as appropriate)
Policy
All practice staff members respect the rights and needs of all patients.
No patient is refused access to clinical assessment or medical treatment on the basis of
gender, race, disability, Aboriginality, age, religion, ethnicity, beliefs, sexual preference
or medical condition. Our practice has implemented provisions to assist all patients to
access our services including <<provide an example, ie. Interpreter services>>.
The practice identifies important/significant cultural groups within our practice including
non-English speaking patients, religious groups and those of Aboriginal and Torres Strait
Islander background. We endeavour to continue to develop any strategies required to
meet their needs.
Patients have the right to refuse any treatment, advice or procedure. Our doctors discuss
all aspects of treatment and will offer alternatives should a patient seek another medical
opinion. Comprehensive documentation of events when patients refuse treatment or
advice, or seek an alternative clinical opinion, are made in the patient record. Contact
should also be made to the treating GPs medical defence organisation.
Patients are provided with sufficient information about the purpose, importance, benefits,
risks and possible costs associated with proposed investigations, referrals or treatments to
enable patients to make informed decisions about their health.
Patients in Distress
There may be times when patients present at the practice in a highly distressed state.
These patients require close monitoring and should be afforded dignity when seeking
help.
When a patient presents at our practice in a distressed state, staff escort the patient to a
spare room, usually the <<insert the room commonly left vacant or used for
emergencies>>, alert the GP about the situation and continue to monitor the patient until
they can be seen by a member of the clinical team. Patients are made comfortable by
offering water or tissues.
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RACGP 4th edition Standards 1.2.1, 1.2.2, 2.1.1, 1.5.2
5.10 Complaints
(Customise as appropriate)
Policy
In our practice, customer satisfaction and patient experience is important to us. All patients
have the right to complain if they feel the service they received did not meet their
expectations.
We have a complaints resolution process which all staff can describe, and we also make
the contact details for the state or territory health complaints agencies readily available to
patients if we are unable to resolve their concerns ourselves. All complaints are attempted
to be resolved at a practice level. Only if a satisfactory outcome is not reached should the
complaint be directed to the Health Care Complaints Commission (HCCC).
Where possible patients and others are encouraged to raise any concerns directly with the
practice team who are trained to handle and respond to complaints. We believe most
complaints can be responded to and resolved at the time the patient or other people makes
them known to us.
Patients have the opportunity to remain anonymous if requested. Our practice complies
with relevant privacy legislation when responding and handling complaints.
All staff should be prepared to address complaints as they arise. Depending on the nature
of the complaint and advice received from medical indemnity company, complaints are
recorded and actioned within a central complaints register. A copy is placed in the
patient’s medical record if the complaint is related to patient care.
All clinical staff and the practice manger are aware of their professional and legal
obligations regarding the mandatory reporting of unprofessional conduct. Contact is
made with the GPs MDO and advice sought on the appropriate action in the event a
complaint relates to clinical care.
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Procedure
Patients and others have opportunities to register their complaints either verbally to staff,
in writing (letter) or via our suggestion box. Patients should feel free to complain
anonymously if desired.
All staff are aware of the complaints management process and are trained to respond
appropriately.
When receiving complaints staff should keep in mind the following in order to minimise
further patient anxiety and hostility, possible leading to litigation:





handle all complaints seriously, no matter how trivial they may seem.
verbal complaints made in person should be addressed in a private area of the
practice where possible.
address the patient’s expectations regarding how they want the matter resolved.
assure the patient that their complaint will be investigated and the matter not
overlooked.
offer the patients the opportunity to complete a formal complaint form. (They
may accept or decline).
All patients are made aware through <<customise as appropriate>> the Practice
Information Sheet and signage in the practice waiting area, of their right to lodge a
complaint and how they can make a complaint. Brochures with contact details for the
HCCC are located in the waiting area and can be generated upon request by practice staff.
The HCCC contact details are also available on the Practice Information Sheet.
It is the responsibility of <<insert person responsible for complaints>> to collect,
investigate and handle complaints. The practice takes the following steps to handle
complaints:



When a patient indicates they would like to make a complaint, ask if they would
like to complete a form.
If verbal, take the patient to a private area and document the details of their
complaint. Be sure to ask the patient if they would like to remain anonymous or
not.
Notify the team member responsible for complaints handling and record the
complaint in the register.
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The person responsible for complaints handling should acknowledge receipt of
the complaint either via telephone or a letter, to advise the patient of the work you
will be conducting to investigate the complaint.
If the complaint is of a clinical nature, contact the GPs MDO for advice and
appropriate action.
Investigate the complaint and work with the patient to achieve a mutually
beneficial outcome.
Discuss the complaint at a staff meeting or clinical meeting (if applicable).
Notify the patient or the whole patient population, of the outcome or relevant
changes to the practice as a result of the complaint.
Record details of the investigation and outcome in the complaints register.
If the matter cannot be resolved advise the patient about how to contact the Health
Complaints commissioner.
The National Privacy Commissioner is able to receive complaints concerning privacy
issues. Complaints here will have a response within 28 days.
National Privacy Commissioner
Privacy hotline 1300 363 992.
GPO Box 5218
Sydney NSW 2001
http://www.privacy.gov.au/complaints
Members of the public may make a notification to Australian Health practitioner regulation
agency (http://www.ahpra.gov.au/) (AHPRA) about the conduct, health or performance of a
practitioner or the health of a student. Practitioners, employers and education providers are all
mandated by law to report notifiable conduct relating to a registered practitioner or student to
AHPRA.
RACGP 4th edition Standards 2.1.2 & 4.1.1
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5.11 Non English Speaking Patients
(Customise as appropriate)
Policy
Our doctors and staff have a professional obligation to ensure they understand our
patients and that the patients understand any verbal instructions or written information.
Patients who do not speak the primary language of our clinical staff or who have a
communication impairment, are offered the choice of using an interpreter service to assist
with clinical consultations. Our practice does not encourage the use of family members or
friends of patients to act as translators unless this is an expressed wish of the patient and
he health problem is only minor.
Our practice also accesses a number of translated health information to assist with
patients who have difficulties reading or understanding English.
Procedure
All patients are asked when registering with our practice if they require the service of a
translator or interpreter. These details are recorded on their medical record.
Our practice advises patients of the availability of translating and interpreting services
via:
 <<List all methods of notification>>
When a patient arrives at our practice with a friend or family member, we ask if they
consent to have them act as a translator and advise of alternative methods available. We
advise the patient that it is practice policy not to have family and friends act as
translators.
In our practice, the following staff are bilingual:
 List staff and languages spoken
Staff are only encouraged to translate for patients in emergency situations or with the
patient’s expressed consent when dealing with minor health issues.
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Whenever a translator is used during clinical consultations, this should be documented in
the patient health record.
A copy of the TIS contact list is available <<insert location of contact details>>. It is
the responsibility of <<insert person responsible>> to ensure this list is updated
regularly and to ensure all client access codes are renewed before expiration.
RACGP 4th edition Standards2.1.1, 1.2.3, 2.1.3
5.11.1 Culturally Appropriate Care
(Customise as appropriate)
Policy
We aim to identify important and significant cultural groups within our practice and have
implemented strategies to meet their needs.
In order to improve health outcomes we:
 encourage and record when our patients choose to self-identify their Aboriginal or
Torres Strait Islander origin or cultural background to practice staff.
 Encourage and record our patients ethnic and cultural background when patients
choose to identify with practice staff
 Are able to access specific guidelines for the clinical care if patients who identify as
Aboriginal or Torres Strait Islander
Patients religious beliefs are respected to the best of our staffs ability. The practice has an
anti-discrimination policy which all staff are aware of.
Procedure
Our practice routinely encourages identifying and recording the cultural background of
our new and existing patients. Cultural background and ethnicity e.g. Aboriginal and
Torres Strait Islander background, can be an important indication of clinical risk factors
and can assist GPs and clinical staff in providing disease prevention and delivering
culturally appropriate care.
The standard indigenous status question asked is ‘Are you of Aboriginal or Torres Strait
Islander origin?’ This question should be asked of all patients, irrespective of appearance,
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country of birth or whether the staff know of the client or their family background. Our
practice collects this information as part of our ‘new patient’ form.
Where our software has the option to input Aboriginal and/or Torres Strait Islander status or
cultural background/s we use the drop down options rather than free text to assist with
extracting the information for accreditation purposes or preventative activities.
To encourage Aboriginal or Torres Strait Islander origin patients to self identify we have
<<insert any measures you have taken e.g. Self identification posters in the waiting room,
Displaying the Aboriginal and Torres Strait Islander flags on brochures, or having the Koori
Mail in your waiting room http://www.koorimail.com>>.
<<Customise as appropriate>>
Our practice staff and GPs have undertaken cultural awareness training to assist in the
development of culturally appropriate services at our practice. Our practice also collects and
records information on patient ethnicity and languages spoken to assist with delivering
clinical care appropriately.
RACGP 4thedition Standards 1.4.1, 1.7.1, 2.1.1
5.12 Directory of Local Health and Community Services
(Customise as appropriate)
Policy
Our practice engages with a range of health, community and disability services to plan
and facilitate optimal patient care to patients whose health needs require integration with
other services.
A readily accessible<<written or computerised>>directory of health and community
services, utilised by patients within our area, including how to refer or contact these
agencies, is maintained and updated regularly. It is the responsibility of <<insert person
responsible>>to ensure this database is updated and maintained on a regular basis.
GPs and other clinical staff are encouraged to advise the person responsible to maintain
the database if new providers are to be included.
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Clinical staff are encouraged to co ordinate patient care across the general practice setting
with other health services and to build good working relationships with these providers to
facilitate collaborative care
Procedure
This directory is located (*Insert how to access your directory of services).
The contact numbers in this list are checked and updated annually or more often if
required, by <<insert person responsible>>. All new staff are made aware of how to
access this list during their induction.
The directory of local health and community services lists:
 local medical/diagnostic services.
 local hospitals and specialist consulting services.
 primary healthcare nurses.
 pharmacists.
 disability and community services.
 health Promotion and public health services and programs.
 relevant Government departments in the Region.
 local allied health services.
 community, social or self help groups in the area.
 culturally appropriate services for non English speaking background and
Aboriginal and Torres Strait Islander patients.
Where possible, a brief explanation about any fees applicable, contact numbers or names
and procedures for interacting with these services is included on this list.
RACGP 4th Edition Standards 1.6.1
5.13 Provision of Brochures, Leaflets and Pamphlets for Patients
(Customise as appropriate)
Policy
There is a range of posters, leaflets and brochures available or on display in the waiting
room, reception and/or consulting rooms. Where appropriate these are available in more
than one language or in formats to assist patients with intellectual impairment.
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Leaflets, brochures and pamphlets can vary considerably in quality. The brochures used
by this practice are carefully selected and screened by clinical staff to ensure they are
culturally appropriate and contain current, evidence based information.
The quality and accuracy of any Audio visual resources or internet sites recommended to
patients or used to provide printed information to patients is also considered.
The brochures, posters, leaflets and pamphlets available include information about health
promotion, and illness prevention, specific diseases, medical procedures and privacy and
patient rights.
The doctors and clinical staff use written information during a consultation to:
 support diagnosis and management of conditions.
 for health promotion and illness prevention
Brochures and educational materials are also available for patients to self select.
Procedure
All health promotion and educational materials are carefully reviewed by members of the
clinical team to ensure they are consistent with the current best practice guidelines. Items
are obtained from reputable sources and, where possible, items should be dated, contain
the name of the source and referenced to supportive evidence.
Our practice regularly obtains brochures from these organisations:
 List organisations which brochures are obtained from
At least annually we conduct an audit of our brochures, leaflets and patient information
sheets to ascertain if they are current and if better options are available.
Brochures and leaflets are displayed in the waiting room or in the consultation rooms.
It is the responsibility of <<insert the name of the person responsible>>to ensure that
brochures are kept up to date, discarded when no longer current and new brochures
incorporated when available.
The provision of specific written material to support advice given in consultations is
encouraged to help patients remember the key messages from the consultation and
address individual patients’ needs.
RACGP 4th Edition Standards 1.2.3, 1.3.1, 1.4.1, 1.2.2
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5.14 Practice Information Sheet
(Customise as appropriate)
Policy
The Practice Information Sheet (PIS) provides patients with adequate information about
our practice to facilitate access to care. It is also a useful way to inform patients of current
practice policies or changes to our services. We endeavour to ensure all patients, new and
existing, are provided with the most up to date version to ensure the information they
have is accurate.
Our practice information sheet is made available at reception and is provided to all new
patients when registering with the practice.
If a patient is unable to read or understand our practice information sheet an alternative
method is used to supply this information. These may include:
 verbally.
 larger font versions.
 through the National Relay Service or AUSLAN for patients who are deaf.
 through the translation and Interpreter service (TIS) for patients who speak
languages other than English.
 getting our sheets translated into languages commonly used at our practice.
<<Customise as appropriate>>
Telephone messages, the on hold recording and our website is also used, where possible,
to reinforce some of the information about our practice and our services
Procedure
The practice information sheet is kept at reception; it is available to all patients and
handed to each new patient on their first visit.
Where patients are unable to read or understand our written sheet we use other means to
communicate the essential information.
To maintain the accuracy of our information sheet it is reviewed regularly and updated as
required. When this sheet is updated the date is inserted in the footer to denote the latest
version. Reception staff are advised there has been a change and are encouraged to bring
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this new version to the attention of our patients. It is the responsibility of <<insert person
responsible>> to review and update the practice information sheet.
The Practice information sheet contains at a minimum:
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practice address and phone numbers
consulting hours and arrangements for care outside our normal opening hours,
including a contact telephone number.
our practice’s billing principles such as bulk billing, accounts settlement,
approximate cost for treatment, potential out of pocket expenses.
our practice’s communication policy including receiving and returning phone
calls and electronic communication (e.g. SMS & email).
our practices policies for the management of patient health information including
that patients can obtain a copy of their health information and where additional
posters or the full privacy policy can be obtained from the practice.
the process for the follow up of results e.g. who will contact whom and by when.
how to provide feedback or make a complaint to the practice (include the contact
for the local state health complaints conciliation body and the name of the person
responsible for feedback and complaints).
Additional information on the practice information includes:<<customise as
appropriate>>
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names and qualifications or special interests of doctors, nurses, allied health and
other practice team members (subject to their consent).
clinical and other services available.
that they can request a summary of the policy on home, hospital, and nursing
home visits.
inform patients that longer consultations are available on request.
encourage ways in which patients can give feedback (e.g. tell patients if you have
a suggestion box).
how patients are able to request their preferred doctor.
inform patients about your reminder systems and the option of opting out of
receiving reminders.
information about how patients can assist by telling the practice if their personal
information changes e.g. changed address or provide any court documentation to
advise any child custody arrangements.
where the practice has a website it should contain at a minimum, the information
required in the practice information sheet. The website information should be
accurate and updated regularly.
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It is the responsibility of <<insert the person responsible>> to ensure copies of the
practice information sheet are available at reception.
RACGP 4thedition Standards 1.2.1, 1.2.3, 1.2.4
5.15 Office Supplies
(Customise as appropriate)
Policy
Supplies of stationery, other office and Practice stores including prescription pads,
letterhead, certificates etc. are accessible only to authorised persons.
Practice office equipment and facilities are appropriate for its purpose and are safe to use.
Regular audits are conducted to review the safety and security of practice equipment and
stationery supplies.
Facsimile, printers and other electronic communication devices in the practice are located
in areas that are only accessible to the general practitioners and other authorised staff.
Faxing is point to point and will therefore usually only be transmitted to one location
Procedure
It is the responsibility of <<insert person responsible>> to monitor the safety and
security of practice equipment and office stationery supplies.
Sensitive practice stationary such as prescription pads and letterheads are located
<<insert location>> and are only accessible by authorised staff.
Reports of broken practice equipment or low levels of office supplies are made to
<<insert person responsible>> to rectify the situation.
RACGP 3rd edition Standards 5.1.1
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6
Privacy and Personal Health Information
6.1
Privacy and Security of Personal Health Information
(Customise as appropriate)
Policy
This practice is bound by the Federal Privacy Act 1998 and National Privacy Principles,
and also complies with the New South Wales Health Records and Information Act 2004.
‘Personal health information’ is a particular subset of personal information and can include
any information collected to provide a health service.
This information includes medical details, family information, name, address, employment
and other demographic data, past medical and social history, current health issues and future
medical care, Medicare number, accounts details and any health information such as a
medical or personal opinion about a person’s health, disability or health status.
All patient health information is considered private and confidential. Disclosure of
patient health information is not conducted without the consent of patient’s and the GPs.
Any information disclosed without consent will result in disciplinary action and possible
dismissal of staff.
All staff working within the practice have signed confidentiality agreements as
conditions of their employment. Information security is discussed at staff induction and
continued education occurs throughout employment.
When patient health information is computerised, electronic measures have been taken to
ensure the safety and security of this information. The person responsible for Information
Technology/Information Management (IT/IM) is <<insert name of person
responsible>> who is charged with the coordinating, implementing and monitoring these
measures.
Our practice complies with both state and federal privacy legislation relating to medical
records. Our practice also complies with the National Privacy Principles.
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For each patient we have an individual patient health record containing all clinical
information held by our practice relating to that patient. The practice ensures the protection of
all information contained therein. Our patient health records can be accessed by an
appropriate team member when required. We also ensure information held about the patient in
different records (e.g. at a residential aged care facility) is available when required.
Procedure
In our practice, patient health information is kept <<edit as appropriate>> using a
paper-based filing system/ electronic filing system/ using a combination hybrid system.
Paper-based records are stored <<insert location of paper-based file storage>>.
In our practice, the following measures are taken to ensure the security and privacy of
patient health information kept as paper records:
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files are stored in a locked cabinet/secure room/secure offsite location.
files are stored in area where constant staff supervision can easily be afforded
files are stored in an area that restricts public access
files are placed out of view from the patient either face down or behind desks in
high patient traffic areas
For records stored electronically, the following procedures are in place to protect patient
health information:
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all staff have individual logins and passwords
staff have restricted levels of access to patient health information depending on
their role
computer screens are located in positions where patient view is obstructed or
blocked
screensavers and automated computer locks are activated during periods of
inactivity
appropriate firewalls and antivirus software is installed and updated regularly
all information electronically communicated is done so using an encrypted
network.
Our practice policy has a documented privacy policy for the management of patient health
information which is available to patients upon request and displayed within the waiting area
or in the Practice Information Sheet. The policy outlines the following:
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practice contact details
what information is collected
reason for the information to be collected
how the security of information is maintained
range of people who may access the information
procedures for access, transfer and disclosure to a third party
contact details if they believe there has been a privacy breach with their information
The maintenance of privacy requires that any information regarding individual patients,
including staff members who may be patients, may not be disclosed either verbally, in
writing or in electronic form, except for strictly authorised use within the patient care
context at the practice or as legally directed.
Whenever sensitive documentation is discarded the practice uses an appropriate method of
destruction including shredding or security bin. Electronic information is securely destroyed
using appropriate electronic equipment and processes.
Hybrid Record Systems
Our practice uses a hybrid record keeping system for patient medical files. To ensure
continuity of care and completeness of the medical record, we ensure that there is an record in
each system indicating where the clinical consultation notes and reports are recorded.
RACGP 4thedition Standards 4.2.1, 1.7.1, 1.2.1, 4.2.2
6.2
Computer Information Security
(Customise as appropriate)
Policy
Our practice has systems in place to protect the privacy, security, quality and integrity of the
data held electronically. Doctors and staff are trained in computer use and our security
policies and procedures. Additional training and policy updates occur when necessary
changes are made.
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<<Insert staff member responsible for IT/IM>> has designated responsibility for overseeing
the maintenance of computer security and our electronic systems and these responsibilities
have been documented in their position description.
All clinical staff have access to a computer to document clinical care. For medico legal
reasons and accurate reporting, staff always log in under their own passwords to document
care activities they have undertaken.
Our practice ensures that all computers and servers used by the practice, comply with the
RACGP computer security checklist and that: <<edit as appropriate>>
 computers are only accessible via individual password access to those in the practice
team who have appropriate levels of authorisation.
 computers have screensavers or other automated privacy protection devices are
enabled to prevent unauthorised access to computers.
 servers are backed up and checked at frequent intervals, consistent with a documented
business continuity plan.
 back up information is stored in a secure off site environment.
 computers are protected by antivirus software that is installed and updated regularly
 computers connected to the internet are protected by appropriate hardware/software
firewalls.
 we have a business continuity plan that has been developed, tested and documented.
Electronic data transmission of patient health information from our practice is in a secure
format.
Our practice has the following information to support the computer security policy:
 current asset register documenting hardware and software including software licence
keys
 logbooks/print-outs of maintenance, backup including test restoration, faults, virus
scans
 folder with warranties, invoices/receipts, maintenance agreements
Inappropriate use of the practices computer systems or breaches of practice computer security
will be fully investigated and may be grounds for dismissal.
This practice has a sound backup system and a contingency plan to protect practice
information in the event of an adverse incident, such as a system crash or power failure. This
plan encompasses all critical areas of the practice’s operations such as making appointments,
billing patients and collecting patient health information. This plan is tested on a regular basis
to ensure backup protocols work properly and that the practice can continue to operate in the
event of a computer failure or power outage.
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Procedure
The person responsible for IT/IM has completed the RACGP Computer Security
Checklist and Self-Assessment. A computer security manual has been specifically
developed to assist with the computer security operations and is located <<insert
location>>.
Our disaster recovery folder stocked with items to enable the practice to operate in the event
of a power failure is located <<Insert location>> and includes the following:
 torches
 paper prescription pads/ medical certificates etc
 appointment schedule printout and manual book
 letterhead
 consultation notes
 manual credit card/payment/Medicare processing equipment
 emergency numbers
 Add additional items as appropriate
RACGP 4thedition Standards 4.2.1 & 4.2.2
6.3
Practice Privacy Policy
(Customise as appropriate)
Policy
National Privacy Principle 5 requires our practice to have a document that clearly sets out its
policies on the collection, handling and storage of patient health information.
This document, commonly called the Privacy Policy, outlines how we handle personal
information collected (including health information) and how we protect the security of this
information. It must be made available to anyone who asks for it and patients are made aware
of this.
The collection statement informs patients about how their health information will be used
including other organisations to which the practice usually discloses patient health
information and any law that requires the particular information to be collected. Patient
consent to the handling and sharing of patient health information should be provided at an
early stage in the process of clinical care and patients should be made aware of the collection
statement when giving consent to share health information.
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In general, quality improvement or clinical audit activities for the purpose of seeking to
improve the delivery of a particular treatment or service would be considered a directly
related secondary purpose for information use or disclosure therefore specific consent for this
use is not required.
Procedure
We inform our patients about our practice’s policies regarding the collection and management
of their personal health information via: <<edit as appropriate>>
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a sign at reception.
brochure/s in the waiting area.
our patient information sheet.
new patient forms – ‘Consent to share information’.
verbally if appropriate.
the practice website.
A copy of our practice privacy policy is located <<insert location>> and is available to
patients upon request.
The practice features the following collection statement on each ‘New Patient’
registration form: <<edit as appropriate>>
“<Insert Medical Practice Name> located at <insert practice address> collects your
personal details and health information to ensure we deliver the best possible healthcare
service. Patients are entitled to access their information at any stage by contacting the
practice or their GP. Your health information may be disclosed to other organisations
over the course of your treatment and these instances will be discussed with you if
required. Failure to provide accurate and comprehensive information could negatively
affect your healthcare. If you have any concerns regarding your privacy, please contact
the practice. “
Prior to a patient signing consent to the release of their health information patients are
made aware they can request a full copy of our privacy policy and collection statement.
Patient consent for the transfer of health information to other providers or agencies is
obtained via a signed transfer form, which is then incorporated into the patient medical
record.
Documents which contain patient health information sent to other health care providers,
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such as referrals, are discussed with patients prior to their distribution. All requests for
access to health information by patients are documented and incorporated into the
medical record.
<<Delete if not applicable>>
All new patients signed registration form is scanned into their medical record/stored in
their medical file.
RACGP 4thedition standards 4.2.1
6.4 3rd Party Requests for Access to Medical Records/Health
Information
(Customise as appropriate)
Policy
Requests for 3rd Party access to the medical record should be initiated by either:
 receipt of correspondence from a solicitor or government agency
 by the patient completing a Patient Request for Personal Health Information
Form
Where a patient request form or and signed authorisation is not obtained the practice is
not legally obliged to release.
Where a patient does not provide consent for 3rd party access, the third party may seek
access under relevant privacy laws.
An organisation ‘holds’ health information if it is in their possession or control. If you have
received reports or other health information from another organisation such as a medical
specialist, you are required to provide access in the same manner as for the records you
create. If the specialist has written ‘not to be disclosed to a third party’ or ‘confidential’ on
their report, this has no legal effect in relation to requests for access under the Health Records
Act 2001. You are also required to provide access to records which have been transferred to
you from another health service provider.
We only transfer or release patient information to a third party once the consent to share
information has been signed and in specific cases, informed patient consent has may be
sought. Where possible de identified information is sent
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Our practice team can describe the procedures for timely, authorised and secure transfer of
patient health information in relation to valid requests.
Procedure
Patient consent for the transfer of health information to other providers or agencies is
obtained on each individual occasion when a request is made.
As a rule no patient information is to be released to a 3rd Party unless the request is made
in writing and provides evidence of a signed authority to release the requested
information, to either the patient directly or a third party. Where possible de identified
data is released.
Written requests should be noted in the patient's medical record. Requests should be
forwarded to the patient’s GP for action.
Requested records are to be reviewed by the treating medical practitioner or principal doctor
prior to their release to a third party. Where a report or medical record is documented for
release to a third party, the practice may specify a charge to be incurred by the patient or third
party, to meet the cost of time spent preparing the report or photocopying the record. This fee
should be disclosed to the patient or third party at the time of the request.
The practice retains a record of all requests for access to medical information including
transfers to other medical practitioners.
A full patient record is never released unless specified for legal reasons, such as a subpoena.
A patient health summary is usually sent to another health care provider and additional reports
or results as required.
Security of any health information requested is maintained when transferring requested
records and electronic data transmission of patient health information from our practice is
in a secure format. A courier service or traceable registered post service is used to send
records to a third party.
The practice’s medical defence organisation is always contacted for advice prior to the
release of patient health information.
RACGP 4thedition Standards 4.2.1 & 4.2.2
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6.5
Request for Access to Personal Health Information
(Customise as appropriate)
Policy
Patients at this practice have the right to access their personal health information (medical
record) under the Commonwealth Privacy Amendment (Private Sector) Act 2000 and the NSW
Health Records and Information Privacy Act 2004. The Act gives individuals a right of access
to their personal health information held by any organisation in the private sector in New
South Wales in accordance with Health Privacy Principle 6 (HPP 6). This principle obliges
health service providers and other organisations that hold health information about a person to
give them access to their health information on request, subject to certain exceptions and the
payment of fees (if any).
Public sector organisations continue to be subject to the Freedom of Information Act 1982.
This practice complies with both laws and the National and Health Privacy Principles (NPPs
& HPPs) adopted therein. Both Acts give individuals the right to know what information a
private sector organisation holds about them, the right to access this information and to also
make corrections if they consider data is incorrect.
Reports from specialists and diagnostic results form part of a patient’s medicl record and
therefore are provided under access regulations.
Amendments to the Privacy Act 1998 apply to information collected after 21st December
2001, however they also apply to data collected prior to this date provided it is still in use
and readily accessible.
We respect an individual's privacy and allow access to information via personal viewing
in a secure private area. The patient may take notes of the content of their record or may
be given a photocopy of the requested information. A GP may explain the contents of the
record to the patient if required. An administrative charge may be applied, at the GPs
discretion, e.g. for photocopying record, X-rays and for staff time involved in processing
request.
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Procedure
Our patients are advised of their right to access their personal information via <<insert
method>>. Our privacy policy is available to patient upon request.
Release of information is an issue between the patient and the doctor. Information will
only be released according to privacy laws and at doctor's discretion. Requested records
are reviewed by the medical practitioner prior to their release and written authorisation is
obtained from the patient.
When our patients request access to their medical record and related personal information
held at this practice, we document each request and endeavour to assist patients in
granting access where possible and according to the privacy legislation. Exemptions to
access will be noted and each patient or legally nominated representative will have their
identification checked prior to access being granted.
A Request for Personal Health Information form is completed by the patient and a copy
is incorporated into the patient health record.
Request by another (not patient)
An individual may authorise another person to be given access, if they have the right e.g.
legal guardian, orif they have a signed authority. Under NPP 2 Use & Disclosure, a
'person responsible' for the patient, if that patient is incapable of giving or communicating
consent, may apply for and be given access, for appropriate care and treatment or for
compassionate reasons. Identity validation applies.
The Privacy Act 1998 defines a 'person responsible' as a parent of the individual, a child
or sibling of the individual, who is at least 18 years old, a spouse or de facto spouse, a
relative (at least 18 years old) and a member of the household, a guardian or a person
exercising an enduring power of attorney granted by the individual that can be exercised
for that person's health, a person who has an intimate relationship with the individual or a
person nominated by the individual in case of emergency.
Each request for access is acknowledged and the specific needs for access are discussed
between the GP and the patient. If a fee will be charged for granting access or preparing
records, this will be discussed with the patient prior to access being granted. Fees are not
excessive and aim to cover any administrative costs.
Before the release of any health information, the GP will contact their MDO to assess
whether data should be withheld. In cases where an access request or data is being
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denied, it will be documented in writing and sent to the patient outlining reasons for this
decision.
Personal health information may be accessed in the following ways:
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view and inspect information
view, inspect and talk through contents with the doctor
take notes
obtain a copy (can be photocopy or electronic printout from computer)
listen to audio tape or view video
information may be faxed to patient
Before any access is granted, the identity of the patient should be confirmed using 3
approved patient identifiers. If access is granted to a guardian, their identity and authority
must also be checked.
If the patient is viewing the data, supervise each viewing so that patient is not disturbed
and no data goes missing.
If a copy is to be given to the patient ensure all pages are checked and this is noted in the
request form.
If the doctor is to explain the contents to a patient then ensure an appointment time is
made.
RACGP 4thedition Standards 4.2.1
6.6
Medical Records Administration Systems
Select the appropriate option for the medical records at your practice, throughout this
section
Our practice uses paper based medical records for the storage or management of patient
health information.
Our practice uses <<Insert name of software>> for the storage or management of patient
health information.
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Our practice uses a Hybrid system to manage Patient medical information. This system
comprises of paper based records and computer records. <<Insert the name of the
software you use and any cut-off dates for paper records>>.
For all consultations, importance communications or correspondence related to a patient
whose record is part of the hybrid system, a record is made in each system indicating
where the consultation notes are recorded.
Before entering, accessing or actioning anything from a patient health record on the
practice system, practice staff correctly identify each patient using three approved patient
identifiers. The approved identifiers include:
 Patient name (both first and surname)
 Date of birth
 Gender (as determined by the patient)
 Address
 Patient health record number (where one exists)
All referral letters written by the practice also contain at least three approved identifiers.
This policy also applies to all patient medical records accessed via telephone enquiries.
Procedure
At each encounter with a patient, whether in person or over the telephone, patients are
asked to state their name, date of birth and address.
Practice staff are cautious not to volunteer their information for confirmation to avoid
errors. All patients regardless of how well known they are to practice staff are asked to
state these details.
All referral letters written by the GPs of our practice contain at least three approved
identifiers.
RACGP 4thedition Standards 3.1.4 & 1.7.1
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6.7
Retention of Records and Archiving
(Customise as appropriate)
Policy
Our practice refers to state and federal legislation regarding the length if time a medical
record must be retained.
For children, records must be kept until the child reaches the age of 25 years old. All
other records must be kept for a minimum of 7 years from the last date of contact.
Other records relating to restricted or controlled drugs, sterilisation and human resources
are kept for the same period as medical records.
Our practice conducts a regular process of culling and destroying patient health records
on a <<insert frequency>> basis. Our practice also conducts a regular process of
identifying and inactivating patient records.
An inactive patient record is considered someone who has not visited the practice or
accessed services at least three times in the past two years.
All records are destroyed in a secure manner to protect the privacy of patients and advice
is sought from the practice MDO before disposal.
Procedure
All inactive paper-based medical records are stored <<insert location>>. Electronic
medical records are designated as inactive using the clinical desktop software.
It is the responsibility of <<insert person responsible>> to conduct a regular culling
process for patient medical records.
All paper-based medical records no longer required to be kept are destroyed using a
secure destruction method. Our practice uses <<insert method>> to securely destroy
records.
If this process is undertaken by an external organisation, the <<insert person
responsible>> will obtain a certificate of destruction.
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RACGP 4thedition Standards 1.7.1, 4.2.1, 4.2.2
6.8
Transfer of Medical Records
(Customise as appropriate)
Policy
Transfer of medical records from this practice can occur in the following instances:
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for medico-legal reasons e.g. record is subpoenaed to court.
when a patient asks for their medical record to be transferred to another practice
where an individual medical record report is requested from another source.
where the doctor is retiring and the practice is closing.
Our practice team can describe the procedures for timely, authorised and secure transfer of
patient health information to other providers and in relation to valid requests.
Procedure
In accordance with state and federal privacy regulations, a request to transfer medical
records must be signed by the patient giving us authority to transfer their records.
The request form should contain:
 the name of the receiving practitioner or practice.
 the name, address (both current and former if applicable) and date of birth the
patient whose record is required.
 the reason for the request.
When fulfilling a request, this practice may choose to either
 prepare a summary letter (manually or via clinical software) and include copies of
relevant correspondence and results pertinent to the ongoing management of the
patient.
 make a copy of the medical record and dispatch the copy to the new practice,
retaining the original on site for a minimum of 7 years.
The requesting clinic is advised if we intend to transfer a summary or a copy of the full
medical record. All attempts are made to ensure that the format is preferred by the
practitioner/practice.
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If there is going to be any expenses related to the transfer, the requesting clinic and the
patient, are advised prior to sending the medical records. Once payment of the fee has
been received, staff process the request as soon as possible.
Any charges must not exceed the prescribed maximum fee.
The patients’ signed request letter/form and a notation when the record was transferred is
made on the medical record retained by our practice. Details about the receiving practice,
date and method of transfer are also documented.
Electronic data transmission of patient health information from our practice is in a secure
format.
All reasonable steps are taken to protect the health information from loss and
unauthorised disclosure during the transfer.
This practice does not allow individuals to collect the file and take it to their new
provider.
RACGP 4thedition Standards 4.2.1, 4.2.2, 1.5.2
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7
Clinical Management
7.1
Clinical Autonomy
(Customise as appropriate)
Policy
Doctors in this Practice are free to make decisions that affect the management of their
patients in accordance with accepted clinical judgement, best available evidence and
adherence to valid clinical care guidelines.
Doctors exercise full autonomy in determining:
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the appropriate clinical care of their patients.
the health professionals including specialists, other general practitioners and
para-medical practitioners to whom they refer.
the pathology, diagnostic imaging or other investigations they order and the
provider they use.
how and when to schedule follow up appointments with individual patients.
whether to accept new patients provided that this action is non-discriminatory and
does not apply to emergencies.
Feedback is sought from doctors and other staff concerning the use of practice
equipment, appointment scheduling and other matters relating to professional autonomy.
All members of the clinical team comply with their professional and ethical obligations
and practice within the boundaries of their knowledge, skills and competence, and their
role within the practice team.
RACGP 4thedition Standards 1.4.2
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7.2
Clinical Content of Medical Records
(Customise as appropriate)
Policy
Each patient at our practice has their own individual patient health record containing all
the health information held by our practice about that patient.
Our practice can demonstrate that the following actions are being completed by staff:
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recording the emergency contact of all patients
recording the Aboriginal and Torres Strait Islander status of patients who wish to
self-identify
recording other cultural backgrounds of patients
recording the allergy status, including ‘no known allergies’, of all patients
updating and monitoring the accuracy of patient health summaries
recording the preventative health care status of patients wherever possible.
The new patient and update patient details form attempt to capture this information to be
incorporated into the patient record.
An audit of patient health records can show that:


at least 90% of active patients have an allergy status recorded
at least 75% of active patients have an updated and current health summary
Procedure
In our practice, our record keeping system is paper-based/ fully electronic/ hybrid
combination system.
All staff members responsible for delivering clinical care have appropriate levels of
access to make clinical notes. Clinical staff are required to document all important
communications with patient in their designated health record. Documentation should
also be sought from practitioners who provide care on behalf of the practice or care
which takes place outside the practice premises.
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At a minimum, consultation notes will include:
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Date of consultation
Patient reason for consultation
Relevant clinical findings
Diagnosis
Recommended management plan and, where appropriate, expected process of
review
Any medicines prescribed for the patient
Complementary medicines used by the patient
Any relevant preventative care undertaken
Any referral to other healthcare providers or health services
Any special advice or other instructions
Who conducted the consultation
At a minimum, patient health summaries will include:
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Adverse drug reactions
Current medicines list
Current health problems
Relevant past health history
Health risk factors (smoking, nutrition, alcohol and physical exercise)
Immunisations
Relevant family history
Relevant social history including cultural background where clinically relevant
All referral letters, correspondence and reports/results relating to patients will be
incorporated into their medical record.
Practice staff who contact the patient for following up care or results, must document in
the patient health record all attempts to contact patients. If access is restricted to
administrative staff, <<insert name of person responsible>> will transcribe this
information at a later stage.
Wherever possible, records must be legible and of a standard which will ensure
continuity of patient care across clinicians. All patient records are accessible by clinical
staff at the time of consultation.
All staff are provided with training during their induction and on an ongoing basis on
how to create and edit patient records.
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RACGP 4th edition Standards 1.7.1, 1.7.2, 1.7.3, 1.1.3, 1.1.4, 1.5.1
7.3
Informed Consent
(Customise as appropriate)
Policy
Our doctors, nurses and other healthcare workers inform their patients of the purpose,
importance, benefits, risks and possible costs of proposed investigations referrals or
treatments, including medications and medicine safety. We believe that patients need to
receive sufficient information to allow them to make informed decisions about their care.
When communicating to patients the risks, benefits, importance and purpose of proposed
treatments or investigations, the following factors are taken into consideration:
 Language barriers including written material in languages other than English
 Patient’s ability to provide comprehensive understanding and informed consent
 Whether a third party is responsible for care
In situations where patients are dependent on a third party for their ongoing care we
endeavour to provide all appropriate information to the carer.
Issues of personality, personal fears and expectations, beliefs and values are also
considered.
Our clinical staff utilise written material including diagrammatic representations to assist
patients to understand the proposed treatments/investigations. In cases where this has
occurred, records are made in the patient health file.
Patients are advised of possible costs involved, including additional out of pocket costs,
for procedures, investigations and treatments conducted on site prior to them being
conducted.
Patients are encouraged to seek alternative clinical opinions in the event they disagree
with the proposed activities of our clinical staff. Refusal to undergo proposed treatment
or expressed interest in seeking another clinical opinion are documented in the patient
health record.
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Procedure
Clear communication is provided about the potential for out of pocket costs including any
unexpected developments and the possible costs of additional treatments or procedures
before proceeding.
All advice relating to proposed clinical care of patients is provided by clinical staff who
have adequate training to supply such information. Under no circumstances are
administrative staff to offer clinical advice or answer any clinically based questions from
patients. If deemed necessary, administrative staff may be asked to witness a patient’s
consent to a procedure once explanations have been provided by the clinical team.
Wherever possible, clinical staff utilise written material to support the explanation of the
costs, risk, benefits, purpose and importance of proposed treatments, medications,
investigations and procedures. In these situations, it is recorded in the patients medical
record when written material is used.
Patients who refuse or wish to seek further clinical opinion for treatment are free to do so.
It is recorded in the patient health file when patient refuse treatment or indicate they plan
to seek alternative opinions. In extreme cases, the treating clinicians MDO will also be
contacted and advice sought.
For children, all medical decisions will be made by parents until the GP has determined
the child is of age to make their own medical decisions. Carers of patients will be
included in the decision making process if the patient is deemed as being unable to make
their own decisions.
RACGP 4th edition Standards 1.2.2 & 1.2.4
7.4
Referral Protocols
(Customise as appropriate)
Policy
Patients may require the services if additional care providers to external to the practice.
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Whenever referral letters are written, the costs, benefits, risks, importance and purpose of
the referral is explained to the patient by the clinician. All referral documents are filed in
the patients medical record.
The practice has an up to date <<edit as appropriate: written or computerised>>
directory of local allied health providers, community and social services and also local
specialists to assist when choosing practitioners to facilitate optimal patient care.
Clinicians are aware of their obligations to provide sufficient clinical handover to other
health care providers when writing referrals and ensure that all information contained
within referral documents is accurate and up to date.
Patients are made aware that their health information is being disclosed in referral letters
and documents.
Procedure
Our directory of local allied health providers, community and social services and also
local specialists is available <<insert how to access this>>. It is the responsibility of
<<insert name of person responsible>> to ensure database is updated and maintained.
For referred services where costs are not known, the patients are advised of the potential
for out of pocket expenses and encouraged or assisted to make their own enquiries. If the
patient indicates that the costs pose a barrier to the suggested treatment or investigation
alternatives may need to be discussed (e.g. referral to public services).
Special care is taken to advise patients of the costs of consultations or procedures that do
not attract a government subsidy.
Letters of referral are <<edit as appropriate: paper or computer based>>. If referrals
are to be sent electronically, the practice ensures that this is performed in a secure manner
to maintain patient privacy. All referral letters are incorporated into the patient medical
record either electronically or by manual scanning.
In the case of an emergency or other unusual circumstance a telephone referral may be
appropriate. All telephone referrals need to be documented in the patient’s health record.
Referral letters should:
 be legible (preferably typed) on appropriate practice stationary.
 contain relevant history examination findings and current management
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include any allergies, adverse drug reactions and a current accurate medications
list.
include the reason/purpose for the referral and expectation of the referral.
identify the Doctor or clinical staff member making the referral.
identify the setting from which the referral is being made
if known, identify the healthcare provider to whom the referral is being made and
the setting
be dated.
contain at least 3 of the approved patient identifiers e.g. name, date of birth and
address.
Clinically significant referrals are followed up.
RACGP 4th edition Standards 1.2.4, 3.1.4, 1.5.2, 1.6.1, 5.3.1, 1.6.2
7.5
Clinical Handover
(Customise as appropriate)
Policy
Clinical handover has been defined by the Australian Medical Association as ‘the transfer
of professional responsibility and accountability for some or all aspects of a patient’s or a
group of patients’ care to another person or professional group on a temporary or
permanent basis’.
Failure or inadequate handover of care is a major risk to patient safety and a common
cause of serious adverse patient outcomes. It can lead to delayed treatment, delayed
follow up of significant test results, unnecessary repeat of tests, medication errors and
increased risk of medico legal action.
Clinical handover communications can be face-to-face, written, via telephone and also by
electronic means.
All staff are informed about our policy on clinical handover to ensure standard processes
are followed.
Clinical handover of patient care occurs frequently in general practice both within the practice
to other members of the clinical team, and to external care providers.
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We have standard and documented processes for timely clinical handover with services
that provide care outside normal opening hours.
Procedure
Clinical handover needs to occur whenever there is a change of care providers. Examples of
clinical handover include:
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a GP covering for a fellow GP who is on leave or is unexpectedly absent.
a GP covering for a part time colleague.
a GP handing over care to another health professional such as a practice nurse,
physiotherapist, podiatrist or psychologist.
a GP referring a patient to a service outside the practice.
a shared care arrangement (e.g. team care of a patient with mental health problems).
When appropriate, the clinical handover is documented in the consultation notes (where
possible).
Written or verbal clinical handover between GPs occurs on a formal arranged basis when
doctors cover for those working on a sessional basis or when a GP or other clinical staff
member is away because of annual leave or illness. In addition to a formal handover,
adequate clinical records, including a health summary and up to date medications list,
enable the routine care of patients to continue. Practitioners relieving for another should
read the patient’s preceding clinical records.
Clinical handover to external health care providers usually occurs through the provision of
referral documents. All referral letters contain sufficient information to facilitate optimal
patient care.
The practice should ensure that sufficient information is provided to the emergency
department about the clinical condition of an inbound patient, to facilitate prompt and
appropriate care. This may be directly to the ambulance service or to the hospital.
Deputising services are responsible for handing the care of a patient back to the patient’s
regular medical practitioner in a timely and appropriate manner. Our practice receives a
notification the following business day whenever a patient of our practice uses the
deputising service. This is incorporated into the patient file and adequately followed up.
RACGP 4th edition Standards 1.5.2 & 5.3.1
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7.6
Follow up of Tests, Results and Referrals
(Customise as appropriate)
Policy
Our practice’s system for the follow up of tests, results and referrals has a strong focus on
risk management.
Our practice team can describe:
 how patients are advised of the process for follow up of results.
 the system by which pathology results, imaging reports, investigations reports and
clinical correspondence received by our practice is reviewed by a GP, signed,
acted upon in a timely manner and incorporated into the patient’s medical record.
 how we follow up and recall patients with clinically significant tests, results or
correspondence.
All test results, including pathology results, diagnostic imaging and investigation reports,
and clinical correspondence received are reviewed, initialled (or electronic equivalent)
and, where appropriate, acted upon in a timely manner. This is all incorporated into the
patient health record.
All test results, pathology, imaging and investigation reports received by the practice are
reviewed, initialled and where appropriate, acted upon in a timely manner.
The nature and extent of the practices responsibility for the follow up of tests and results
will vary from case to case and will be determined by:
 the probability that the patient will be harmed if follow up does not occur.
 the likely seriousness of the harm.
 the burden of taking steps to avoid the risk of harm.
In cases where patients have indicated they will not attend a recommended test or in
circumstances where the likely harm of non-attendance is high, the patients are flagged in
the reminder system by the treating GP. These patients should be followed up to ensure
that recommended test are carried out or the situation documented in the patient health
record.
The need to recall patients should be considered in the overall context of the patient
including their history and significance of the health issue. The treating GP or their
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designated representative is the person who is responsible for making the decision on
which patients to recall.
When contacting patients for the follow up of results, our practice will attempt to contact
the patient by telephone three times before sending a letter to their designated address.
All attempts are documented in the patients medical record.
Sometimes our doctors may need to be contacted outside normal working hours by the
pathology service about a serious or life threatening result. We have provisions for
doctors to be contacted after hours for life threatening or urgent results.
Our patients (or their carers) are made aware of their obligations and responsibilities for
their own healthcare. This includes being informed about how to obtain their results and
the seriousness of not attending for ordered appointments/investigations and any recall or
subsequent follow up. Where appropriate this advice may be documented in the patient’s
medical records.
In addition to an appreciation of the need for timeliness when following up and actioning
referrals, tests and results, our staff members are also aware of the need for
confidentiality and discretion with regard to referrals, diagnostic tests and results or
correspondence.
Procedure
Write your practice procedure for the follow up and recall of test results. Please note the
key points below when writing your procedure.
Your practice procedure must outline how the practice:
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ensures timely action of follow up
ensures that GPs initial all results before being filed. This includes the electronic
equivalent
ensure that results are incorporated into the patient record
identifies the team members responsible for each step of the system
manages non-response from patients
ensure continuity if care for patients including how it is incorporated into the
medical record
ensures patient privacy when following up results
RACGP 4th edition Standards 1.1.4 & 1.5.3
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7.7
Reminder Systems for Preventative Care
<<Delete if your practice does not have a Reminder System>>
(Customise as appropriate)
Policy
We are working towards a systematic approach to the entry of patient data in the medical
records to facilitate the search, extraction and utilisation of patient information for our
prevention and screening activities. This includes comprehensive patient health
summaries
and documentation of preventative activities in the patient’s medical records.
Consideration of patient’s individual circumstances is encouraged when providing
information about health promotion and illness prevention for patients (and carers).
Verbal and written information is provided to patients about health promotion and
specific disease prevention. This is distinct from the education and information that is
provided to patients to support a diagnosis and choice of treatment.
Wherever possible, our practice coordinates with other health care services and state
registers including:

List all registries that the practice participates in
We also maintain specific disease registers through our clinical desktop system as part of
our commitment to chronic disease management.
Patient permission is sought before placing their name on a proactive reminder system
and this permission is recorded on the patient file. Details of how the patient can opt out
of this system are also available to the patient via <<insert method of notifying patients,
ie. Practice information sheet>>.
Procedure
Write your practice procedure for actioning the reminder system. Please note the key
points below when writing your procedure.
You may want to include the following:
 an outline of the roles of administrative and clinical staff,
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how you select patients,
how you search clinical data e.g. any data extraction tool used,
how you ensure all staff are aware of preventative activities,
samples of letters or the templates used
list specific risk factors or diseases you target
RACGP 4thedition Standards 1.3.1
7.8 3rd Party Observing or Clinically involved in the
Consultation
(Customise as appropriate)
Policy
Consent must always be obtained from patients prior to a 3rd Party Observing or being
clinically involved in the consultation.
This includes medical or nursing students, a person included at the doctor’s request, an
interpreter or person to assist with communication, a chaperone, or someone accompanying
the patient to the consultation at the patient’s request such as a carer or relative.
In some circumstances the patient or the GP may feel more comfortable if there is a
chaperone present during the consultation. For medico legal reasons it is recommended to
consider offering a chaperone for unaccompanied children.
Procedure
Wherever possible, we ask the patient to consent to a 3rd Party being present during the
consultation when making the appointment and confirm that this consent remains upon arrival
for their appointment.
Where prior consent was not obtained, the patient is asked to consent to the presence of a 3rd
party before entering the consultation room. It is not acceptable to ask permission for a 3rd
party to be present during the consultation in the consulting room as some patients may feel
unable to refuse.
Practice staff are mindful of the particular needs of people with intellectual disabilities
who may not be able to provide consent. In such cases a legal guardian or advocate may
need to be appointed to oversee the interests of the patient.
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Our practice uses signage or other written information to inform patients about the
presence of medical or nursing students.
RACGP 4th edition Standards 1.2.3 & 2.1.3
7.9
Practice Participation in Research Projects
(Customise as appropriate)
Policy
Our practice <<does/does not>> participate in external research projects.
Whenever any member of our practice team is conducting research involving our
patients, we can demonstrate that the research has appropriate approval from an ethics
committee. The research protocol, consent procedures and process for resolving problems
is retained by the practice.
When we collect patient health information for quality improvement audits or professional
development activities, we only transfer de-identified patient health information to a third
party. Whenever identifiable patient information must be transferred, we always seek patient
consent prior to transmission and ensure the privacy of information is maintained.
Procedure
Research projects involving patient care:
 must have the explicit and documented written consent of the patient
 the patient must receive a written and oral explanation about the research and be able
to withdraw consent at any time
 the project must be approved by a relevant human research ethics committee (HREC)
established under the NH&MRC guidelines.
 privacy laws must be adhered to
The practice should retain a record of the request for participation in any research project,
including the research protocol, consent procedures and process for resolving problems
should be retained by the practice.
RACGP 4thedition Standards 4.2.1
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7.10 Management of a Patient Refusing Treatment or Advice
(Customise as appropriate)
Policy
This practice takes an active approach to ensure the best outcomes for patients at all times
even if they choose to reject investigation and/or management advice.
Our practice endeavors to help our patients understand the importance of medicines and
treatment advice to help them make informed decisions about their health care.
Our clinical team can demonstrate how we provide care for patients who refuse a specific
treatment, advice or procedure.
Procedure
Staff and doctors are to respect the right of all patients to make investigation and treatment
choices or to seek a further clinical opinion.
Patients should be advised to notify their doctor or nurse if they plan to seek another clinical
opinion. Patients should also be advised that if they choose to follow another healthcare
providers management plan, to notify their doctor or nurse.
An appropriate risk management strategy to be followed includes ensuring that:
 The patient has been provided with the full range of options available, including the
risks and benefits of each to enable them to make an informed choice.
 The consequences of the choices made are explained including those of
non-investigation and treatment.
 Documentation of the explanation and actions taken by the patient should be made in
the patient medical record.
RACGP 4thedition Standards 2.1.1
151
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7.11 Refusal to Treat a Patient
(Customise as appropriate)
Policy
The practice or individual clinical team members have the right to refuse to treat patients in
defined circumstances. Our practice ensures arrangements are made for the timely transfer of
the patients care to another member of the clinical team either within our practice or to
another healthcare service.
Procedure
GPs or other clinical staff may refuse to treat patients for a number of reasons including:
 Threatening or violent patient behaviour
 Breakdown in the therapeutic relationship
 Patient healthcare needs are outside the scope of the practitioner
 Scaling back the practice patient load
Any refusal to treat a patient is done for substantial reasons not based on discrimination.
Patients in emergency situations will always be treated to the best of our ability. Emergency
medical treatment is defined as treatment that is necessary to:
 save a patient’s life
 prevent serious damage to health
 prevent or alleviate significant pain or distress
An appropriate risk management strategy to be followed in these circumstances includes
ensuring that:
 the patient has been provided with reasons about why they cannot have ongoing
treatment at this clinic.
 the patient has been provided with alternative possible treatment locations and written
referrals, if appropriate.
 any complaints that may arise are dealt with according to the complaints procedure.
 full documentation of the actions taken above in the medical record is essential.
Our practice will endeavor to assist such patients with ongoing care including referral to other
health care providers and transfer of any medical history.
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RACGP 4th edition Standards 2.1.1
7.12 Practice Equipment
(Customise as appropriate)
Policy
Our practice has all the necessary equipment to provide comprehensive primary care and
emergency resuscitation. The practice staff ensure that these are maintained, safe and in a
serviceable condition at all times.
The available equipment is sufficient for the procedures commonly performed within our
practice and meets the needs of our patients.
All equipment that requires calibration or is electrically or battery-powered, are maintained
according to manufacturer’s instructions and are documented on a maintenance schedule.
Members of the clinical team are consulted about the equipment and supplies the practice uses
or purchases.
Our practice has timely access to spirometry and electrocardiography via <<insert method of
access, ie. internally or local diagnostic centre>>.
Procedure
The practice has the necessary medical equipment to ensure comprehensive primary care and
resuscitation, including the following:
 auriscope
 blood Glucose monitoring equipment
 disposable syringes and needles
 equipment for resuscitation, equipment for maintaining an airway (including airways
for children and adults), equipment to assist ventilation (including bag & mask), IV
access, and emergency medicines
 examination Light
 eye examination equipment (e.g. fluorescein eye staining)
 gloves (sterile & non-sterile)
 height measurement device
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at least one height adjustable patient examination couch
measuring tape
monofilament for sensation testing (10g Nylon)
ophthalmoscope
oxygen
patella hammer
peak flow meter or Spirometer
scales
spacer for inhaler
specimen collection equipment
sphygmomanometer (small, med and large cuffs)
stethoscope
surgical Masks
thermometer
torch
tourniquet
urine testing strips
vaginal Specula
visual acuity charts
x Ray viewing facilities
Our practice also has the following additional equipment based on the particular needs and
interests of our clinical team:
 List any additional equipment, for example, a defibrillator.
Relevant staff are trained in the care, use and maintenance of equipment and where
appropriate to analyse and interpret any results.
Liquid Nitrogen and oxygen are hazardous materials and are therefore stored securely and
staff are trained in their safe use.
The maintenance schedule for equipment is kept <<insert location>>. It is the responsibility
of <<insert person’s name>> to schedule regular equipment maintenance and to document
these in the schedule.
RACGP 4thEdition Standards 1.4.2 & 5.2.1
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7.13 Doctor’s Bag
(Customise as appropriate)
Policy
All of our doctor’s have access to a fully equipped doctor’s bag for emergency care and
routine off site visits. When not in use, the doctor’s bag is stored securely and checked on
a regular basis.
In some instances doctors may share a doctor’s bag or items may be kept in two smaller
bags. Required items may be added to the bag prior to use to avoid doubling up on
equipment. Where doctors’ bags are shared, the arrangements are reviewed on an
ongoing basis to ensure that doctors have access to a bag when required. Additional bags
are purchased if required.
Sensible security measures are taken at all times and any relevant legislation or
regulations relating to S8, S4 and drugs of dependence are adhered to.
The doctors should consider the practice location, health needs of the community and the
type of clinical conditions likely to be encountered when determining the contents and
drugs to be kept in the doctor’s bag. Regular checks should be performed to stock the
supplies and dispose of expired stock.
Procedure
When attending an off site consultation or emergency each doctor has a fully equipped
doctor’s bag containing:
 auriscope
 disposable gloves
 equipment for maintaining an airway in both adults and children
 in date medicines for medical emergencies
 opthalmoscope
 practice stationary (including prescription pads and letterhead)
 sharps container
 sphygmomanometer
 stethescope
 syringes and needles in a range of sizes
 thermometer
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tongue depressors
torch
It is the responsibility of <<insert person’s name>> to stock take and replenish items
from the doctor’s bag on a <<insert frequency>> basis. Ideally, the doctor’s bag should
be re-stocked after each use.
The bag contents, including equipment and stock levels of drugs, are systematically
checked. All drugs must be “in date” and the dangerous drug register accurate and
completed. Any out of date items are discarded as per policy.
When not in use the doctor’s bag is stored securely <<insert location>>. If stored with a
doctor’s personal items, arrangements are made for the secure storage of the bag whilst
the GP is on leave.
RACGP 4thEdition Standards 5.2.2
7.14 Vaccine Storage
(Customise as appropriate)
Policy
We ensure that all vaccines are acquired, stored, administered, supplied, and disposed of in
accordance with the manufacturer’s directions and jurisdictional requirements.
Vaccine storage requires constant maintenance of the 'cold chain' to ensure vaccine potency.
The 'cold chain' refers to the system of transporting and storing vaccines within the safe
temperature range of between 2ºC - 8ºC.
We have a staff member with designated responsibility for ensuring our cold chain
management processes comply with the current edition of the national vaccine storage
guidelines and for conducting an annual audit of our vaccine storage procedures. This role is
defined in their position description.
We have documented protocols for the monitoring of vaccine storage including equipment
maintenance and auditing procedures.
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Procedure
Tasks associated with maintaining the cold chain of vaccine storage may be delegated to other
staff members, however <<Insert the name and position of the staff member>> has primary
responsibility to:
 ensure our vaccine storage procedures comply with the “National Vaccine Storage
Guidelines”.
 communicate these guidelines to staff and develop documentation of the procedures.
 provide adequate training to other staff appropriate for their role
 ensure there is a process for handing over the cold chain responsibility to another
designated person when they are unavailable to perform their duties.
 conduct an annual self audit of our vaccine storage
 to ensure appropriate actions are taken if the temperature has been outside the
recommended range.
 maintain the vaccine storage equipment and temperature recording thermometer.
Please refer to the vaccine storage protocols located <<insert location>>. These
protocols are reviewed by <<insert person responsible for vaccine storage>> on a
<<insert frequency>> basis.
RACGP 4thedition Standards 5.3.1 & 5.3.2
7.15 Medication Prescribing and Administration
(Customise as appropriate)
Policy
Our clinical team ensures that at each patient encounter where medications are prescribed
or discussed, patients are adequately informed about the purpose, importance, benefit and
risks of their medicines. Patient’s ability to comprehend verbal and written material is
taken into consideration and the use of translators is considered, where appropriate.
As part of our clinical team’s ongoing professional development and commitment to
contemporous medical practice, all clinical team members can demonstrate access to
current medicines information and prescribing guidelines.
Medications lists for each patient are updated by a member of the clinical team at every
patient encounter. Patient allergies are also recorded in each patient file to minimise risk
of negative drug interactions.
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Patient education is an important element whenever medications are prescribed. Written
material such as consumer medicines information, are used to help patients understand
their medication and this is documented in the patient health record.
Procedure
To reduce the risk of medication errors when prescribing or referring, all GPs and clinical
staff take the following steps:
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update the patient medication list at each patient encounter including removing
single-use medications
Discuss the risks, benefits, importance and purpose of all prescribed medications
Provide written materials to support verbal discussions with patients regarding
medications
Record patient allergies in the medical record and confirm at each prescribing
encounter
Where appropriate, provide patients with a copy of their medications list
Enquire and record the complimentary medications status of all patients
If required, use translators or translated material to assist patients to comprehend
medication instructions and information
These activities are recorded in the patient’s medical record whenever they are
undertaken.
Our clinical team currently has access to the following prescribing guidelines and
resources:
 List all guidelines and resources currently available to clinical staff, ie.
Australian Medicines Handbook.
RACGP 4thedition Standards 5.3.1
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7.16 Controlled Substances
(Customise as appropriate)
Policy
Schedule 4 and Schedule 8 poisons (inc. doctor’s bag emergency drugs, professional samples
and vaccines) are obtained on the authorisation of a medical practitioner(s). These drugs are
the responsibility of the medical practitioner(s) and subject to regulatory controls.
Nurses are not permitted to be in possession of S4 or S8 drugs. Only under written
instructions from the general practitioner may they access the drugs and administer them
under practitioner supervision. Only when the medical practitioner is present can nurses
access the drug.
S8 poisons must be stored in a locked facility, fixed to the floor or wall. Storage facilities
for Schedule 8 poisons must remain locked at all times except when it is necessary to
open it to carry out an essential operation such as medical treatment, stock checks and
reordering. Keys & combinations must not be accessible to or known by unauthorised
persons. Keys cannot be left on the premises over night.
When required to be transported for use in other locations, S8 drugs must be stored in a
locked receptacle (e.g. doctors Bag), in the doctors possession. If the receptacle is
necessarily out of the doctor’s immediate possession it should be secured, out of sight, in
a lockable facility (e.g. locked cupboard or locked vehicle) to prevent unauthorised
access.
Up to 6 divided doses of a S8 drug, for emergency use, may be stored in a locked facility
that does not comply with legislative requirements. These doses must be kept in a central
location or receptacle in a room that can be locked when a medical practitioner is not in
attendance.
Schedule 4 poisons including sample packs may be stored in a filing cabinet, cupboard or
drawer, within the practice. If an authorized person (usually a medical practitioner) is present,
the storage facility may remain unlocked at their discretion. This option requires the storage
facility to be locked when the authorized person/s are not present.
S4 drugs of dependence are either stored in the same manner as other S4 poisons or in the
drug cabinet with S8 poisons again at the discretion of the authorised person.
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Schedule 4 vaccines that require refrigeration must be stored in either:
 a lockable refrigerator that is locked when an authorized person (usually a
medical practitioner) is not present.
 or in a refrigerator secured within a lockable room that is locked when an
authorized person is not present.
Nurse Immunisers should familiarise themselves with legislative issues that are applicable to
their situation.
Records of all transactions including supply acquisition and disposal of S4 and S8 drugs, must
be true and accurate and entered on the day that the action occurred. These records must be
retained for a minimum period of 7 years and are kept in the same location as the drugs.
Any alterations or cancellations of entries in the drug register must not be made. Any
mistakes that require correction should be done as a footnote with initial and dates. Each
brand name and strength of drugs kept must be detailed on a new page in the register.
Stock checks are to be conducted every March and September, or within one month of
assuming control of the practice. This should be recorded under the last entry and clearly
labeled as “Balance in Hand”. Lost, stolen or destroyed drug register must be reported to the
Pharmaceutical Services Branch.
The destruction of S4 or S8 drugs must only be performed in the presence of a pharmacist to
act as a witness. The destruction must be documented in the practice drug register and
include the pharmacists name, professional registration number and date of destruction. Both
parties must sign the entry.
S4 and S8 labels will require:
 the name of the patient,
 the date of dispensing and if necessary an identifying code,
 the name , address and telephone number of the medical clinic or doctor providing
supply including the name of the prescribing doctor
 directions for the correct use of the medicine
 directions for storage and expiry date (may be those on the packet if left uncovered).
 the brand and generic names of the drug including strength and form.
 the words “KEEP OUT OF THE REACH OF CHILDREN”
 ancillary labels as specified in the “Australian Pharmaceutical Formulary”.
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When prescribing or supplying S4 and S8 medications the doctor takes all reasonable steps,
given the time and circumstances that exist at the consultation to ensure a therapeutic need
exists. Prescribing to maintain an addiction is not a therapeutic need and is illegal.
RACGP 4thedition Standards 5.3.1
For information on jurisdictional requirements refer to the drugs and poisons branch of the
relevant jurisdiction:
New South Wales
Pharmaceutical Services Branch NSW Health
Telephone: 02 9879 3214 Fax: 02 9859 5165
7.17 Clinical References and Resources
(Customise as appropriate)
Policy
Consistency and quality of care can be assisted by the use of current resources, access to
clinical guidelines and communication between team members. This process is encouraged
and facilitated by the practice clinical leader.
This practice provides our clinical staff with access to a range of resources and materials for
reference on clinical matters and items of interest for professional development.
The references available contain information that is consistent with current practice guidelines
or based on best available evidence. In the absence of well conducted trials or other higher
order evidence the opinion of consensus panels of peers is acceptable. References and
resources including practice guidelines should be accessible at the point of care. Wherever
possible, all resources are dated and contain the name of the source.
There is an organised system of access for all practice staff to journals, clinical guidelines and
other reference material. The clinical references available and any new additions, deletions or
updated versions is communicated to all staff and clinical team members to assist with
consistency in the approach to diagnosis and management of patient care. Distribution occurs
at either formal clinical meetings or electronic methods, and are documented in the <insert
location, ie. communication book or notice board>>.
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Procedure
<<Insert the guidelines and references readily available at your practice and how or where
they can be accessed>>
At least annually we conduct an audit of our clinical resources and references to ascertain
if they comply with current practices and are providing consistent management and
information to patients across the practice team. It is the responsibility of <<insert
person’s name>> as clinical leader to conduct this audit.
It is a standing item at our clinical meetings to discuss any new clinical issues, resources
or clinical practice guidelines.
RACGP 4thedition Standards 1.3.1, 1.4.1, 5.3.1, 3.1.3, 3.1.2
7.18 Drug Storage and Disposal
Please note: RACGP 4th Edition Standards state “Practices must comply with
jurisdictional requirements on Schedule 4 and Schedule 8 medicines.” The requirements
can vary in different states and Territories of Australia. Failure to comply with the
legislation renders individuals and practice entities liable to prosecution. Compliance
with legislation does not ensure compliance with other professional standards and other
accreditation requirements which should also be observed.
(Customise as appropriate)
Policy
Perishable medical supplies including vaccines, pharmaceutical and medical consumables
are correctly stored, stock rotated and discarded if past expiry dates.
Our practice has appointed a designated person to take primary responsibility for the
proper storage and security of medicines, vaccines and other healthcare products. All
medications in our practice are stored according to legislative requirements or in a
manner that ensures the safety of our patients and staff. A list of all the locations where
medical consumables are stored within the practice is located <<insert location>>.
Perishable medical items are acquired through regular stock ordering and samples
acquired from pharmaceutical company representatives. All stock orders are recorded
<<insert location and method>>. Samples accepted from pharmaceutical representatives
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are also entered in this log and can assist with the disposal and/or return of expired
medications.
Procedure
<<Insert name and position title of the designated person>> maintains a log of areas to
be checked containing perishable medical stock.
All stock is checked on a <<insert frequency of checking>> basis. Items with expired
‘use by dates’ are to be withdrawn from active storage locations and disposed of
immediately using appropriate methods.
Any drugs which are subject to legislative regulation are disposed of according to strict
instructions. All other expired medications and other consumables from our practice are
disposed of via <<insert method, ie. Local pharmacist takes them>>.
It is the responsibility of all staff who use or dispense medical consumables to check the
expiry date prior to use.
RACGP 4thedition Standards 5.3.1
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8 Continuous Improvement
8.1 Risk Assessment & Management
(Customise as appropriate)
Policy
This practice has multiple systems to regularly monitor, identify and report near misses and
mistakes in both clinical care and general operation.
The practice has appointed a designated member of staff (*insert name) to have primary
responsibility for our risk management systems. These may include clinical and non clinical
risks and events. Specific areas of responsibility can be delegated to other nominated
members of the practice team and these particular responsibilities are documented in the
relevant position descriptions.
The aim of risk assessment and management is to:
 identify all strategic risks using a risk management process.
 ensure risk management becomes part of day to day management.
 co-ordinate the undertaking of regular formal risk assessments and reviews with staff
involved.
 provide staff with education, policies and procedures necessary to manage risk.
 ensure employees are aware of risks and how to manage them.
 assign responsibility for overseeing the practice risk management systems to
designated staff, and document this in their position description.
 document and regularly review our risk management systems.
 monitor risk profile and implement a continuous improvement approach to risk
management.
 ensure successful implementation of changes and improvements made to our risk
management systems.
Our practice has a documented system for dealing with near misses and mistakes and we
ensure that doctors, nurses and other staff involved in clinical care are educated in what to do
and whom to notify when a slip, lapse or mistake occurs, or when there is an unanticipated
adverse outcome. Any improvements that are implemented to prevent identified slips, lapses
and mistakes or potential risks are documented and the practice team is informed.
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Our practice has protocols for Non Medical Emergencies which are kept <<insert
location>>. All staff are given training about non-medical emergencies during orientation.
Procedure
Staff use the “Adverse Outcome Report” to report any slips, lapses or near misses in clinical
care or deviations in patient care that might result in harm. The medical defence organisation
is contacted for all events that may have an adverse outcome.
All accidents or near misses are fully investigated by practice staff and the findings discussed
at a staff meeting to prevent them occurring again. Staff use the ‘Accidents and Near Misses’
register to record all events within the practice when a non-clinical event occurs which causes
harm or has the potential to cause harm. Where appropriate, the workplace insurance
company is contacted for advice and recommended action.
Some of the tools and strategies used in this practice to manage risk include:
 achievement of RACGP standards via the accreditation process
 regular staff and clinical meetings including effective communication with our staff.
 appropriate staff qualifications, induction and training.
 patient feedback obtained via surveys/Suggestion Box /logbook of complaints/
comments <<delete where appropriate>>
 documentation of sterilisation procedures including servicing, details of individual
loads/cycles and staff training
 comprehensive medical records and back up of electronic data.
 documentation/ tracking of abnormal results.
 regular reviews of systems and procedures especially as a result of any analysis of
reported near misses.
 logging/recording of telephone exchanges with patients
 ensuring correct identification of patients at each face to face, telephone and electronic
encounter
 documented contingency plans for events that may disrupt care or stretch practice
resources to the limit, including disasters and disease outbreaks.
RACGP 4thedition Standards 3.1.2 & 4.1.2
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8.2
Review of Policies & Procedures
(Customise as appropriate)
Policy
Policies and procedures relating to the administration of this practice are formally
reviewed on an annual basis or when changes occur requiring earlier review or revision
(e.g. equipment changes).
Policies and procedures are an important component of the practice quality improvement
program, as well as forming the basis for staff induction and ongoing training. Our
practice ensures that all policies and procedures comply with the RACGP Standards for
General Practice.
Procedure
Each designated leader is responsible for conducting a review of the policies and
procedures relevant to the following areas:
 Cleaning
 Complaints Management
 Infection Control
 Information Technology
 Quality Improvement
 Risk Management Systems
 Sterilisation
 Vaccine Management
Discussion and suggestions for improvement to quality, patient safety or policies and
procedure is a standing item on our practice meeting agenda. Staff may informally
approach the Practice Principal or Manager with suggestions for new policies and
procedures or with revisions to existing policies and procedures, at any time.
The Practice Principal, in consultation with the Practice Manager and staff, approve all
policies and procedures. Once approved, documentation is amended in this manual and
elsewhere as necessary.
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Analysis of practice data may also inform any changes to services or other practice
activities to improve the health outcomes of our patients. These quality improvement
activities may necessitate a new or revised written protocol.
Formal revision and final approval of all new and revised policies and procedures is
presented at a staff meeting. To ensure all staff are aware of new policies and recent
changes we have a distribution plan.
RACGP 4thEdition Standards 3.1.1, 3.1.3, 4.1.1
8.3 Continuing Staff Education
(Customise as appropriate)
Policy
The practice GP’s, nurses and other health care providers employed by this practice are:
 appropriately qualified, trained and competent.
 able to provide evidence of training qualifications and of appropriate current
national registration.
 participate in continuing education relevant to their roles and can provide
evidence of this.
 have undertaken training in CPR within the last 3 years. In the case of GPs, this
training must be in accordance with the RACGP QI&CPD recommendations or
at least to the same.
 Able to demonstrate they work within their scope of practice relevant to their role
The administrative staff such as receptionists and practice managers, who do not provide
clinical care:
 have undertaken training in CPR within the last 3 years.
 have undertaken training relevant to their role within the past 3 years.
 can describe or provide records of such training.
Records of GP continuing professional development activities including CPD points and
activity details are retained by individual GP’s and a copy must be given to the Practice
Manager to retain for the practice records annually.
The practice supports continuing professional development for all of the staff it employs.
Details of activities & dates are recorded and should be retained by the Practice Manager.
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Copies of these records or an annual summary should be given to staff for their own
personal records.
All Doctors, Nurses and staff involved in clinical care practice within their legal scope of
responsibilities. We encourage our staff to maintain their knowledge, skills and attitudes
through membership to their professional specialty organisations. The practice has access
to documented copies of relevant scope of practice guidelines.
Both in house and external training programs are utilised. Staff should obtain a certificate
of attendance or evidence of participation and completion for all training, even informal
training sessions (e.g. provided by the General Practitioners or other staff in the practice).
It is acknowledged that some crucial areas for staff training exist, depending on the staff
member’s role and responsibilities. These training requirements are met according to the
training schedule and documented in each staff member’s employment record. All staff are
given adequate infection control training for their role. It is the responsibility of the
designated infection control leader to ensure this training occurs.
Education is not limited to professional technical skill updates but includes a variety of
training and educational activities in areas of need as they arise.
Staff are encouraged to identify any training needs they may have and seek to find
training to meet these needs. Usually this occurs in consultation with their supervisor and
this process should be documented.
Staff training may include:
 education at formal institutions.
 educational seminars attended.
 online training.
 in service education given by company sales representatives or other staff.
 reading Journals, evidence based guidelines or researching information for the
practice.
New staff are supported with any training they may require to perform their role. This
may be identified prior to commencement or during the induction phase. (Initial 3
months).
Procedure
The practice GP’s, nurses and other health care providers involved in clinical care must
provide evidence of current registration each year. Further evidence on training relevant
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to their roles including QI&CPD records or other professional development is kept by the
practice.
Copies of certificates and training records for clinical team members are kept <<insert
location>>. This record also includes approved CPR training completed within the last 3
years.
Administrative staff must also show evidence of relevant training for their role. Copies of
training certificates are kept <<insert location>>. If training is provided internally or
informally by other staff members, this is recorded on the training register located <<insert
location>>. Administrative staff can also demonstrate triage and CPR training completed
within the last 3 years.
All employees of the practice have a completed training induction checklist located <<insert
location>>.
The practice team member with delegated responsibility for staff education on infection
control documents in each individual staff training records how the induction program and
additional ongoing training provided (as identified through discussion and competency
assessment) covers infection control as relevant to each staff members role. Training and
regular updates should include:
 hand hygiene
 standard precautions & Transmission based precautions including PPE use and the
triage of patients with potential communicable diseases.
 dealing with blood and body fluid spills and managing exposure to blood or body
fluids.
 principles of environmental cleaning and reprocessing of medical equipment.
 where to find information on other aspects of infection control in the practice.
 safe handling and disposal of clinical and general waste.
RACGP 4thedition Standards 3.2.1, 3.2.2, 3.2.3, 5.3.3
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8.4
Accreditation & Continuous Improvement
(Customise as appropriate)
Policy
This practice is committed to attaining and where possible, exceeding the Standards for
General Practice 4th Edition as defined by RACGP.
The practice team is committed to encouraging quality improvement and identifying
opportunities to make changes that will improve the clinical care of patients and activities to
promote health in the overall practice population.
The practice uses patient and practice data to identify opportunities for improvement and to
monitor evidence of improvement occurring.
Our practice can demonstrate improvements we have made in response to the analysis of
patient and others feedback, including complaints, and where appropriate we provide
information to patients about improvements made as a result of their input or feedback.
Our practice undertakes quality review activities such as audits, routine data checks, accounts
reviews and medical record reviews on regular basis. Any interesting findings or changes
made as a result of reviews are discussed at practice or clinical meetings.
Procedure
Discussion and suggestions for improvement to quality and patient safety is a standing
item on our practice meeting agenda. The designated staff member for quality
improvement shares all information related to this topic with staff on a regular basis.
Our practice regularly reviews practice data, policies and procedures to help facilitate quality
improvement. Wherever possible, patient feedback and complaints are incorporated into
quality improvement activities and we endeavour to notify patients through special bulletins
whenever changes do occur as a result.
The practice participates in a formal, peer-review process known as accreditation. Our
practice accreditation expires on <<insert expiry date>>. Our practice endeavours to comply
with all relevant legislation and guidelines relating to general practice.
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RACGP 4thedition Standards 2.1.2, 3.1.1, 3.1.3
8.5
Patient Feedback
(Customise as appropriate)
Policy
Our practice encourages patients and other people to give feedback, both positive and
negative, as part of our partnership approach to healthcare, and we have processes in place for
responding to feedback
In order to respond to patient feedback and make improvements, practices need to identify the
person in the practice with primary responsibility for examining issues raised by patients and
facilitating improvements in the practice. In our practice, the designated staff member is
<<insert name and role>>.
Where possible patients are encouraged to raise any concerns directly with the practice team
and attempts are made for a timely resolution of such concerns within the practice in
accordance with our complaints resolution process.
We seek structured /systematic patient experience feedback at least once every 3 years which
meets the requirements outlines in the RACGP publication “Learning from our patients”.
Feedback collected includes, but is not limited to, the following 6 categories that are
considered critical to patient’s experiences within healthcare facilities.
 access and availability
 information provision
 privacy and confidentiality
 continuity of care
 communication skills of the clinical staff
 interpersonal skills of clinical staff
The data collected is analysed and the findings, including any improvements made, are
communicated back to our patients.
As part of our Risk Management Activity, a log of incidents, including complaints, is
maintained in an event log and the incident is noted on the patient’s history. All
improvements made to the practice as a result of patient feedback are discussed at practice
meetings and recorded in the minutes.
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Procedure
At any time patients may provide feedback or make a complaint.
A notice is displayed in the waiting room and details are included in the practice information
sheet to advise patients how to make a complaint to our practice. We also advise the contact
information for the State/Territory health complaints agency and the commonwealth agency.
Staff are trained to ensure patients of the practice feel confident that any feedback or
complaints made at the practice will be handled appropriately. All staff are aware and can
identify the staff member responsible for complaints handling.
At least every 3 years we use a systematic method for collection patient experience
feedback.
We have purchased or downloaded a copy of the RACGP publication “Learning from our
patients” <<insert where this is located>> and we meet the requirements outlined in this
publication.
We collect feedback using: <<delete those not applicable to your practice>>
 an RACGP approved questionnaire
 an individual practice specific questionnaire we have developed which has been
approved by the RACGP
 a series of focus groups with patients which complies with the RACGP guidelines
 a series of interviews with patients which comply with the RACGP guidelines
Data collected is analysed to identify potential opportunities for quality improvement.
We communicate the findings of our feedback and any improvements made back to our
patients using either a poster in the waiting room, newsletters, the website or individually as
appropriate.
Complaints and patient feedback are discussed at practice meetings to facilitate whole of
practice improvement.
RACGP 4th edition Standards 2.1.2
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8.6
Continuity of Care
(Customise as appropriate)
Policy
This practice aims to encourage patients to develop a positive relationship with their doctor
and practice staff over time to enhance the provision of high quality comprehensive patient
care including effective health promotion and strategies for the early detection of disease.
Our practice has systems and procedures in place to help facilitate continuity of care for
patients when visiting our practice including management and informational continuity. All
staff are trained in how they can facilitate continuity of care.
Our medical notes demonstrate relational, management and informational continuity of
comprehensive care. In addition 50% of our active patient health records have entries
extending back over two years.
Our practice provides home visits for our patients and has an agreement with an after hours
provider who provides communication back to the practice about the nature of any after hours
care delivered.
Procedure
Our practice implements the following procedures or systems to facilitate continuity of care:

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
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Comprehensive medical records including an updated patient health summary
Referral letters which contain a minimum of 3 approved patient identifiers, updated
medication list and sufficient information for the ongoing management of the patient
Regular clinical meetings where clinical practice guidelines are discussed and
information shared about patient cases within the practice
A formal clinical handover system to account for clinical staff member leave or
unexpected absence
A robust recall and reminder system for all important test results
Patient are able to request their GP of choice when making an appointment and
administrative staff working to try and ensure their GP is available.
If cases where patients do not request their regular GP, the administrative staff attempt
to book an appointment with the GP from their last visit.
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All staff are able to describe how continuity of care in our practice is facilitated.
RACGP 4thedition Standards 1.1.1, 1.4.1, 1.5.1, 1.5.2
8.7
Clinical Governance
(Customise as appropriate)
Policy
The RACGP 4th Edition Standards describe Clinical governance as a ‘system through which
organisations are responsible for continuously improving the quality of their services and
safeguarding high standards of care by creating an environment in which excellence in
clinical care will flourish’.
We recognise that good clinical leadership is required to engage the entire practice team in a
commitment to excellence by nurturing a culture of openness and mutual respect that allows
just and open discussions about areas for improvement.
We aim to develop an organisational culture where participation and leadership in safety and
quality improvement are resourced, supported, recognised and rewarded and all staff feel
accountable and involved in monitoring and improving care and services.
To promote clear lines of accountability and responsibility for encouraging improvement in
safety and quality of clinical care and the sharing of information about quality improvement
and patient safety within the practice team we have appointed leaders who have designated
areas of responsibility for safety and quality improvement systems within the practice.
Our practice leaders oversee the delegation of tasks to others but retain accountability for
quality and safety. Roles and responsibilities are specified in our position descriptions and all
members of the practice team are aware of the designated leadership responsibilities of key
staff.
Our leaders promote compliance with the RACGP 4th Edition Standards for general practice
and relevant jurisdictional legislation or accepted industry requirements.
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Procedure
All members of our practice team can identify the staff members with primary or delegated
responsibility for:
 Clinical Risk management systems including receiving and disseminating any
important communication or updates (e.g. health alerts) and contingency plans
 Clinical leadership
 Quality improvement and risk management (non clinical)
 Clinical care
 Information management
 Human resources
 Feedback and complaints
 Occupational Health and Safety (Health and Safety representative)
 Electronic systems and computer security
 Proper storage and security of medicines
 Cold chain management
 Infection control within our practice. (e.g. sterilisation process, staff immunisation,
staff education).
 Environmental cleaning,
These responsibilities are noted in position descriptions. Our leaders can delegate specific
areas of responsibility to other nominated members of the practice team and these particular
responsibilities should be documented in position descriptions.
RACGP 4thedition Standards 3.1.3, 5.3.1, 5.3.2, 5.3.3, 4.1.1, 4.2.2
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