Chief Psychiatrist policy

This page includes information about the following Chief Psychiatrist policy.

   

PolicyPatient records (PDF 169 kB)

This policy is mandatory for all authorised mental health services (AMHSs). An authorised doctor, authorised mental health practitioner (AMHP), AMHS administrator, or other person performing a function or exercising a power under the Mental Health Act 2016 must comply with this policy.

You can also find additional fact sheets, forms, clinical notes and resources that are available for these policies under the relevant subtopics on this page.

Managing patient health records

An accurate, comprehensive and up to date patient record management system supports mental health clinicians and AMHS administrators in delivering high quality treatment and care and upholding the rights of involuntary patients.

AMHS administrators are required to ensure that data relevant to the assessment, treatment and care of patients under the Mental Health Act 2016 is:

  • accurate and up-to-date, and
  • that all Mental Health Act 2016 related documents are electronically entered or uploaded to the patient record.

Consumer Integrated Mental Health and Addiction (CIMHA) application

The CIMHA application is a statewide consumer-centric clinical information system which is the designated patient record for the purposes of the Mental Health Act 2016.

Read the policy for more information or find out more about CIMHA

What you must discuss with patients

The Mental Health Act 2016 requires persons, such as authorised doctors and AMHPs, to tell, explain or discuss particular matters with patients.

The matters that must be explained or discussed with patients include:

  • patient rights
  • examinations
  • assessments
  • treatment and care of patients including in relation to treatment in the community
  • certain matters affecting persons in custody
  • psychiatrist reports
  • regulated treatment such as electroconvulsive therapy (ECT)
  • transport and security at AMHSs.

The person who is required to discuss or explain a matter with a patient must:

  • take reasonable steps to ensure the patient understands the information
  • tell or explain the matter to, or discuss the matter with, the patient in an appropriate way having regard to the patient’s age, culture, mental illness, ability to communicate and any disability
  • tell or explain the matter to, or discuss the matter with, the patient in a way the patient is most likely to understand, for example, in the patient’s language.

Read the What you need to discuss with patients fact sheet (PDF 636 kB) for more information.

Written notices and documents must also be provided to patients in some situations. Learn more about notifying patients, written notices and treatment and care.

Guidance for sharing patient information

For most people with a mental illness, the meaningful engagement of people who play a significant part in their lives is an important part of their recovery. It is fundamental to a consumer centred approach that information is shared as often as possible between clinicians, consumers and those involved in helping a person’s recovery.

In keeping with best practice, clinicians should ensure that everyone identified as important to the consumer is appropriately engaged and involved in the consumer’s treatment and care.

The Clinical Excellence Queensland Information sharing guidelines: Between mental health staff, consumers, family, carers, nominated support persons and others (PDF 315 kB) apply to all Queensland Health mental health, alcohol and other drugs staff.  The guidelines:

  • set out the various legislative frameworks that apply to patient information sharing
  • provide information about when and how to share information about people receiving treatment from Queensland Health services.

Queensland Health has also established information sharing agreements and Memorandums of Understanding (MoUs) with other government departments for people who are accessing, or who may access, Queensland Health mental health, alcohol and other drugs services.

View our interdepartmental agreements

Last updated: 5 September 2024