Policies and Procedures


  • 1. Purpose

    To provide advice to The Royal Children's Hospital (RCH) how RCH protects the privacy of patient and staff personal information.

    2. Scope

    All RCH staff.

    3. Definition of terms

    Personal Information is factual data or opinion about an individual who may be identified, directly or indirectly, by the material.  It can be in any medium including electronic or paper records, video or audio recordings, clinical photography, x-rays, or labels on pathology samples.

    Examples include:

    • An individual's name, signature, address, phone number or date of birth
    • Bank account details
    • Employee record information
    • Photographs.

    Sensitive information is personal information that includes information or an opinion about an individual's:

    • Racial or ethnic origin
    • Political opinions or associations
    • Religious beliefs or affiliations
    • Philosophical beliefs
    • Membership of a professional or trade association
    • Sexual orientation or practices, or criminal record
    • Health information.

    Health information is defined as information or opinion about:

    • The health or disability of an individual
    • Past, present, and future provision of health services
    • Other personal information collected to provide or in providing a health service
    • Other personal information collected in connection with organ, tissue, or body substance donation
    • Genetic information.


    From 8th August 2020, a shared Electronic Medical Record (EMR) between RCH, the Royal Melbourne Hospital, The Royal Women’s Hospital and Peter MacCallum Cancer Centre (the Parkville Health Services) will allow the Parkville Health Services to access a patient’s record if that patient has been treated at any of the Parkville Health Services. Staff at each of the Parkville Health Services are required to adhere to their health service’s policies and /procedures regarding the collection, use, and disclosure of patient information, including this policy. Staff must only access records contained in the EMR as required as part of their role (e.g. if involved in or supporting care and treatment of that patient). Access to the EMR is audited regularly to monitor staff compliance. The records may not be retained locally or deleted. They may not be printed, disclosed, used, or amended for reasons other than patient care and treatment and only in accordance with RCH policies and procedures.

    In accordance with legislation and with procedures, RCH is committed to ensure the privacy of personal information and its appropriate usage.

    RCH is committed to;

    1. Meeting all legislative requirements
    2. Ensuring the privacy of patients and staff information
    3. Ensuring personal information is kept in a safe and secure environment
    4. Ensuring access to personal information is appropriately monitored
    5. Ensuring that information collected is accurate, objective and factual
    6. Informing staff about the correct management of person information and ensuring its privacy
    7. Informing staff, patients, and their families about their rights to access personal information
    8. Ensuring all data breaches are investigated and assessed, and eligible data breaches are notified to the appropriate authority.


    Chief Financial Officer. 

    Related procedures

    Related policies 

    Related legislation

    Click here to access copies of the following legislation on the Victorian Government web-site.

    • Child Wellbeing and Safety Act 2005
    • Children and Young Person's Act 1989
    • Family Violence Protection Act 2008 (Vic)  
    • Freedom of Information Act 1982 (Vic)
    • Freedom of Information Regulations 1998 (Vic)
    • Health Records Act 2001 (Vic)
    • Health Services Act 1988 (Vic)
    • Mental Health Act 2014
    • Privacy and Data Protection Act 2014 (Vic)
    • Public Records Act 1973


    This policy and associated procedures are integral to the RCH achieving its vision of 'A world where all kids thrive'.


    • Curious
      We are creative, playful and collaborative.
    • Courageous
      We pursue our goals with determination, ambition and confidence.
    • Inclusive
      We embrace diversity, communicate well, build connections and celebrate our successes together.
    • Kind
      We are generous, warm and understanding.