Requirements for Information Communication (2007 Edition)

Definitions

Page last updated: 14 January 2008

Access audit trail
A record of views of an individual’s health record data without modification by people, recording (as a minimum) date, time, patient identifier and person viewing. Access to data performed regularly as part of routine operations may be recorded to a lower degree of specificity. (see also ‘audit trail’)

Aggregated data
Data about a collection of patients, which by its nature makes the identification of individuals difficult.

Audit trail
A chronological sequence of audit records, each of which contains evidence directly pertaining to and resulting from the execution of a business process or system function.

Authentication
The process that verifies the claimed identity of a station, originator or individual as established by an identification process. Authentication ensures that the individual or organisation is who they claim to be.

Comment: Authentication of the origin of a message received from an alleged sender may be by means of direct telephone dial, virtual private network with password or with digital certificates (secure socket layer [SSL], or public key infrastructure [PKI]).

Clinical acknowledgment
A record of acknowledgment that a clinician has received and is taking responsibility for acting on results; this may be delivered by any means including phone, and clinical application acknowledgement.

Clinical application acknowledgment
A computer generated acknowledgment by the receiving clinical application confirming receipt and processing of data.

Edit audit trail
A record of additions and alterations to an individual’s health record, including (as a minimum) date, time, patient identifier, instrument and/or authorising person, and the nature of the edit.

Electronic report
A report message transmitted using computer.

Electronic request
A request message transmitted using computer.

Referral
A request plus specimen or patient.

Comment: For purposes of this document, a referral constitutes a request accompanied by a specimen. For instance, (1) a consumer presents at a collection centre with a request form from a practitioner; or (2) a sample plus referral form is received by a laboratory from a surgery. A request per se does not constitute a referral, and a laboratory has no control over whether, in case (1), the consumer presents for sample collection, or to which laboratory they may present. In case (2), the laboratory cannot determine the forwarding of collected specimens together with requisite request forms.

Request
A requisition received to perform a test on a patient without the physical presence of a patient or specimen. It can be paper or electronic.

Third-party access
Access by a party other than the original requester or original ‘copy to’ party; usually this would be a hospital, specialist or a new general practitioner.

Third-party enquiry
A request by an entity other than the original requesting authority for a copy of a report(s). This is considered a ‘directly related secondary purpose’.

Transport acknowledgment
A computer or machine generated acknowledgment confirming delivery of a message to a location; this ensures, to a reasonable degree of certainty, that a message has been successfully delivered, but does not ensure that a clinician has taken appropriate and timely responsibility to act; this applies equally to electronic messages and facsimile transmissions (a facsimile transmission is not deemed successful until a transport acknowledgment is received).

Urgent
‘Requiring immediate attention’ as determined by the requesting practitioner or by the laboratory (Concise Oxford Australian Dictionary 1997).