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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.7 Content of patient health records

Our patient health records contain sufficient information to identify the patient and to document the reason(s) for a visit, relevant examination, assessment, management, progress and outcomes.

Criterion 1.7.1

Patient health records

For each patient we have an individual patient health record containing all the health information held by our practice about that patient.

Indicators

► A. There is evidence that each patient has a legible individual patient health record containing all health information held by our practice about that patient.

► B. Where our practice has an active hybrid medical record system, for each consultation/interaction, our practice can demonstrate that there is a record made in each system indicating where the clinical notes are recorded.

► C. Our active patient health records include patient identification, contact and demographic information (where appropriate) including:

  • the patient’s full name
  • date of birth
  • gender
  • contact details.

► D. Our practice can demonstrate that we routinely record the person the patient wishes to be contacted in an emergency.

► E. Our practice can demonstrate that we routinely record Aboriginal and Torres Strait Islander status in our active patient health records.

F. Our practice can demonstrate that we are working toward recording the other cultural backgrounds of our patients in our active patient health records.

Explanation

Key points

  • Practices need to ensure that where a patient’s information is held in different records it must be available when needed
  • Practices need to routinely record the person the patient wishes to be contacted in an emergency (not necessarily the next of kin)
  • This criterion cross references to Criterion 1.2.2 Informed patient decisions.

Dedicated patient health records

Practices need to have an effective system whereby a patient’s health information is stored in a dedicated patient health record. Health records need to include: the patient’s contact and other demographic information, medical history, consultation notes (including care outside normal opening hours and home visits), letters received from hospitals or consultants, other clinical correspondence, investigations or referrals, and results. Besides clinical information, the patient health record may also contain other relevant information pertaining to the patient such as any WorkCover or insurance information or relevant legal reports.

It is critical that patient health records are legible so that another practitioner could take over the care of the patient if necessary. Not only does written information need to be legible (able to be read and understood), if the practice scans documents such as external reports, the scanning needs to be undertaken in a way that reproduces the legibility of the original document.

Culling information from paper based record systems

Ease of storage may be assisted by culling outdated test results that no longer have clinical relevance (in line with relevant state and territory legislation regarding the retention of patient health information). In these circumstances, the practice needs to have a system for the timely identification of information that is no longer relevant. General practices may want to consult their GPs’ medical defence organisations when determining the practice’s policy regarding culling results.

Risks of hybrid and paper record systems

There are potential risks associated with hybrid patient health record systems, where some information is recorded on a computer (eg. medicines list) and some information on paper notes (eg. past medical history). When the patient notes are stored in two areas it is possible for important issues to be overlooked, particularly if another doctor sees the patient. To make this less of a problem, a note in each system improves the continuity of these hybrid systems.

If health information about a patient is kept in two sites (as in the case of hybrid records or records held in a residential aged care facility), practices need to ensure all the information is available and accessible when needed.

In the interests of risk management, the RACGP recommends that practices with hybrid patient health record systems work toward the electronic recording of at least allergies and medications.

Collecting information from patients

The information required from new patients might be collected by practice staff having new patients complete a generic form, or by interviewing patients in a private environment before consultation. Practices should also have a system whereby patient information is updated regularly so that it remains current and accurate. Practices should routinely record the person the patient would like contacted in an emergency.

Recording cultural background

Practices in all clinical settings should work toward identifying and recording the cultural background of all patients since this background can be an important indication of clinical risk factors and can assist GPs in providing relevant care.

Recording Aboriginal and Torres Strait Islander status

The standard indigenous status question is: ‘Are you of Aboriginal or Torres Strait Islander origin?’ This question should be asked of all patients, irrespective of appearance, country of birth or whether the staff know of the client or their family background.

Sometimes practice teams feel concerned that obtaining Aboriginal or Torres Strait Islander status can be perceived as discriminatory. However, the information is very important because of the different health needs of Aboriginal and Torres Strait Islander people. The practice may wish to collect this information as part of a patient questionnaire and preface questions on cultural background by explaining that such information helps the practice provide appropriate healthcare.

The AIHW National best practice guidelines for collecting Indigenous status in health data sets provide useful background information and practical advice and are available at: www.aihw.gov.au/indigenous-australians/indigenous-identification.

Indicators E and F apply prospectively. The practice may wish to seek information on cultural background from existing patients through a simple mechanism such as an update-your-information questionnaire.

Standard 1.7 Content of patient health records

Our patient health records contain sufficient information to identify the patient and to document the reason(s) for a visit, relevant examination, assessment, management, progress and outcomes.

Criterion 1.7.1

Patient health records

For each patient we have an individual patient health record containing all the health information held by our practice about that patient.

In a nutshell

Your patients must each have a dedicated health record where your clinicians document the minimum required personal, social and other health information in order to facilitate an ongoing and high level of care. These health records also need to contain all documents your service holds that relate to patients, including correspondence, test results and reports (such as legal and WorkCover reports).

Key team members

  • Staff responsible for obtaining initial patient health records (such as the receptionist or Aboriginal health worker)
  • Clinical staff
  • Health service manager

Key organisational functions

  • Patient records policy and processes
  • Electronic records policy
  • Culling policy
  • Patient confidentiality and privacy policy
  • Patient informed consent policy

Indicators and what they mean

Table 1.14 explains each of the indicators for this criterion. Refer to Criterion 1.7.1 Patient health records of the Standards for general practices for explanations of some of the concepts referred to in this criterion. 

Table 1.14 Criterion 1.7.1 Patient health records
IndicatorWhat this means and handy hints
▶ A. There is evidence that each patient has a legible individual patient health record containing all health information held by our practice about that patient. Each of your patients needs to have a dedicated health record containing the health information your practice holds about them. It is important this information is legible and up to date and that it routinely includes:
  • patient identification, contact details and demographic information (where appropriate) including cultural information such as language or clan affiliations
  • medical history
  • consultation notes, including notes from out-of-hours care providers and home visits
  • letters and correspondence from hospitals, consultants and health and allied health professionals
  • clinical correspondence, investigations, referrals and test results
  • reports, correspondence and information relating to each patient that may have a bearing on their emotional and physical well-being. This includes WorkCover and legal reports.
▶ B. Where our practice has an active hybrid medical record system, for each consultation/interaction, our practice can demonstrate that there is a record made in each system indicating where the clinical notes are recorded. There are inherent risks associated with a hybrid system because it increases the chance of insufficient recording of information, or of recording information in the wrong system. Where a hybrid system exists, your health service needs to minimise these risks by ensuring that:
  • notes are kept in both types (or sites) of records to maintain continuity of information for doctors and other clinical staff
  • records are easily accessible and available when needed.
In the interest of risk management, the RACGP recommends that where a hybrid system exists, services work towards moving to electronic recording of important and clinically significant information such as allergies, adverse drug reactions and medications.
▶ C. Our active patient health records include patient identification, contact and demographic information (where appropriate) including:
  • the patient’s full name
  • date of birth
  • gender
  • contact details.
Active patient health records should include, at a minimum, the patient identification and contact information identified in this indicator. You could also include demographic information, where appropriate; this includes cultural information such as language, clan affiliations and other health service-approved patient identifiers. Patient identifiers could include:
  • patient name (family and given, and/or cultural, skin, clan or bush name)
  • date of birth
  • gender
  • address (may be recorded as community, outstation or homeland)
  • hospital record number or equivalent
  • family relationships
  • for a patient who was part of a multiple birth, the order in which they were born (for example, the second of twins).
▶ D. Our practice can demonstrate that we routinely record the person the patient wishes to be contacted in an emergency. Your patient information should also include an up-to-date emergency contact; a process is also needed for doing this. For example, at the return of a patient who has not been to your service in a while, you may require them to fill out an updated patient information sheet. Alternatively, prompts could be built into electronic records for clinical staff to ask the question.
▶ E. Our practice can demonstrate that we routinely record Aboriginal and Torres Strait islander status in our active patient health records. Recording a patient’s Aboriginal and Torres Strait Islander status provides important information for clinical staff in their treatment. It is important because differences in clinical risk factors between Aboriginal and Torres Strait Islander peoples and other cultural groups dictate how clinical staff approach a patient’s healthcare.

All patients should be asked the question ‘Are you of Aboriginal or Torres Strait Islander origin?’ regardless of their appearance, country of birth or whether staff know them or their family background.

The RACGP position is that this standard national question should be asked in all general practices. However it recognises that many ACCHSs use the three-part definition, which consists of:
  • descent (of Aboriginal and Torres Strait Islander descent)
  • self-identification (identifies as Aboriginal or Torres Strait Islander)
  • community recognition (accepted as Aboriginal or Torres Strait Islander by the community they live in).
F. Our practice can demonstrate that we are working toward recording the other cultural backgrounds of our patients in our active patient health records. A patient’s cultural background can provide important indicators of clinical risk factors, as some factors are more prevalent in different cultural and social groups. Recording cultural backgrounds in patient records that reflect evidence-based clinical risk factors could be a good start in meeting this criterion. This alerts doctors to tailor clinical assessment and consultation to the patient’s underlying health needs.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure that it maintains patient health records for its patients. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality 
to their community.

Every patient of the health service has an individual electronic patient health record. If a staff member records an episode of care in a patient’s paper-based health record, a note is also entered into the patient’s electronic health file to refer to the paper-based record and vice versa.

Patients’ health files identify the person the patient wants to be contacted in case of emergency and staff are aware this may not be the same person who is listed as the next of kin.

The service’s staff training includes cultural awareness and safety training. This teaches staff to ask new patients to complete a new patient form, which asks if the patient identifies as Aboriginal, Torres Strait Islander or Aboriginal and Torres Strait Islander or any other cultural background. This is so staff members can provide health prevention and management activities for Aboriginal and/or Torres Strait Islander patients.

Information about patients is correctly and consistently recorded in their active patient health records. If a patient is unable to read, a staff member will take the patient to a consulting room and go through the form with them and document their answers. Existing patient details are updated annually with this additional information, using a similar form. The service also updates electronic and paper-based patient health records with any changes to patient information regarding Aboriginal and Torres Strait Islander status.

Annual reports submitted to funding bodies include the numbers of Aboriginal, Torres Strait Islander, Aboriginal and Torres Strait Islander and non-Indigenous patients of the service.

Health service clinical and program staff members provide monthly statistics to management, which include the numbers of Aboriginal, Torres Strait Islander, Aboriginal and Torres Strait Islander and non-Indigenous patients seen by staff.

Administration staff collate and review data received by Medicare Australia in relation to the service’s participation in the Practice Incentives Program Indigenous Health Incentive.

The service has an information disaster recovery plan to retrieve electronic patient health records in the event of an adverse incident, such as a system crash or power failure. The plan is tested on a regular basis to ensure backup protocols work properly. See also the case study for Criterion 4.2.1 Confidentiality and privacy of health information.

Showing how you meet Criterion 1.7.1

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Maintain individual health records for each patient.
  • Ensure handwriting in paper-based health files is legible.
  • Ensure documents scanned into electronic health records are clear and easily able to be read.
  • Ensure that, where a hybrid medical record system is used, both electronic and paper health records have a record of a consultation. For example, if the consultation was recorded in the paper health record then an entry is made in the electronic record, noting that the full consultation notes are to be found in the paper record.
  • Conduct interviews with staff members.
  • Ensure patient health record audits show:
    • 
the name of the person the patient would like contacted in an emergency; this may not be the same person listed as their next of kin
    • 
identification of Aboriginal and/or Torres Strait Islander status for all patients.
  • Maintain up-to-date new and current patient forms.
  • Show that you cover patient health records during  staff inductions.
  • Maintain patient health files.
  • Utilise Medicare Australia Practice Incentives Program Indigenous Health Incentive data.
  • Send annual reports to funding bodies.
  • Maintain a policy and procedure manual.

Related RACGP Standards 
and criteria

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