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adverse reactions, immunisations) Event Summaries – created by other providers (e.g. pharmacists, emergency department) Hospital discharge summaries Pathology and diagnostic imaging reports Prescribed and dispensed medication Specialist and referral documents Medicare, PBS and PRBS information Organ donor decisions Immunisations Personal health notes written by individual or an authorised representative: Contact numbers and emergency contact details key health data (from primary care) Vaccination and immunisation status Outpatient reports Pathology report Imaging Mother-child pass Wills Precautionary powers medical register specialists – an overview of services received over time Referrals – from healthcare professionals Contact details of primary physician and other health professionals Reason for medication Anticipatory care information e.g. care of long term conditions Communication preferences End of life care Immunisations Exclusions: Sensitive information like fertility treatments, sexually transmitted infections, pregnancy terminations and gender reassignment are not automatically included. Emergency Care Summary Laboratory results Imaging results Investigation requests Appointments Encounter and discharge letters read codes are automatically included) Baseline functional and clinical status, including capacity Triggers for deterioration Current care needs and arrangements Emergency contacts and next of kin details How far to escalate care Preferred of care, and final care, other specific patient/carer wishes Palliative care information Legal issues such as power of attorney DNACPR status Special alerts – for example around staff safety Current problems or diagnosis Results of in the previous year, for example, blood tests and x-rays
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