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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 1.7.2

Health summaries

Our practice incorporates health summaries into active patient health records.

Indicators

► A. Our practice can demonstrate that at least 90% of our active patient health records contain a record of known allergies.

► B. Our practice can demonstrate that at least 75% of our active patient health records contain a current health summary. A satisfactory summary includes, where appropriate:

  • adverse drug reactions
  • current medicines list
  • current health problems
  • relevant past health history
  • health risk factors (eg. smoking, nutrition, alcohol and physical activity)
  • immunisations
  • relevant family history
  • relevant social history including cultural background where clinically relevant.

C. Our practice has documented standardised clinical terminology (such as coding) which the practice team uses to enable data collection for review of clinical practice.

Explanation

Key points

  • Health summaries assist in providing ongoing care, both within the practice and on referral to other healthcare providers
  • Health summaries need to be developed on a progressive basis and kept up-to-date
  • Practices need to routinely record known allergies in the health record
  • Coding has many beneficial uses that improve patient care including practice audit, identifying patients with particular medical conditions (eg. chronic disease registers for conditions such as diabetes) and other quality improvement activities
  • ‘Known allergy’ means a hypersensitivity reaction to a medicine or other substance that is made known to a GP
  • ‘Adverse drug reaction’ means harm that results from a medicine.

Health summaries for safe and high quality care

A vital component of a quality health record is a health summary. The RACGP encourages practices to aim for all active records to contain an up-to-date health summary. A good health summary assists the patient’s own GP, other GPs in the practice, locums, registrars and students to rapidly obtain an overview of all components of the patient’s care. Health summaries reduce the risk of inappropriate management including medicine interactions and side effects (particularly when allergies are recorded). Health summaries provide the social and family overview vital to whole patient care. A health summary will assist with health promotion by highlighting lifestyle problems and risk factors (eg. smoking, alcohol, nutrition, physical activity status). It also helps disease prevention by tracking immunisation and other preventive measures.

This criterion applies to active patient health records only. An ‘active patient health record’ is a record of a patient who has attended the practice/service three or more times in the past 2 years. The medical records of patients who have attended the practice in the past 2 years should all have a health summary.

Even if a patient has only attended the practice once, the content of the summary should contain, as a minimum, sufficient information for the GP to safely and effectively provide care for the patient. The specific details listed would vary depending on the nature and context of the consultation (eg. a child with a minor laceration would generally not need to have a detailed past and family history, but immunisation details, especially tetanus immunisation, allergies, current medical problems and current medications could be relevant). Similarly, should a patient attend while on a round Australia trip and need to have a repeat of medications, it would be expected that a list of current medications and adverse drug reactions as well as current and past history would be documented in the health summary.

Practices with high numbers of recurrent, transient patients (eg. those in resort areas) will need to identify health records of regular patients for review if undertaking an external peer review.

Known allergies

While it is important to record all known allergies in the health record, it is particularly important to record adverse drug reactions as this facilitates safer prescribing (especially when computer based) and reduces the likelihood of adverse patient outcomes. Where there are no known allergies, it is important to record ‘no known allergies’ in the patient’s health record to indicate this has been checked with the patient. Where a practice uses a hybrid health record system, it is particularly important that the allergy status of the patient is recorded in the same system that is used for prescription writing.

Social history and recent important life events

The recording of recent important events covers a wide range of social events of importance to the patient, which may include changes in accommodation, family structure (eg. birth of children, separation or divorce, death of family members) and employment. Recent important events can alter patient preferences and values and the context of care.

It is also important to record aspects of a patient’s social history which may signify an increased risk of poor health (eg. Aboriginal or Torres Strait Islander status, refugee status, homelessness, sexuality and gender identity). The RACGP appreciates that family and social history especially should only be recorded in a health summary where it assists patient care and does not affect a patient’s right to privacy. As such, not all health summaries will include all the items listed in Indicator B. Where an appropriate member of the practice team checks with the patient and then determines there is no relevant health, family or social history, this should be recorded in the health summary to indicate the appropriate questions have been asked of the patient. The RACGP recognises that in some situations such as Aboriginal medical services and refugee health services, social and family histories may be collected by team members other than the GP (eg. Bringing Them Home coordinator, trauma counsellors).

Active patient health records

An active patient health record is defined by these Standards as the record of a patient who has attended the practice/service three or more times in the past 2 years. There is an expectation that practices which do not meet the 75% requirement at survey will achieve this threshold by the time of their next survey.

Coding

Consistent data coding systems drive meaningful quality improvement activities. Coding is an effective means to address issues of having consistent clinical terminology. This can be readily addressed by means of a software system that uses ‘drop down box functionality’ in defining medical diagnoses. Coding can form the basis of chronic disease registers and avoids the confusion that can result from ‘free text’ style descriptions in the medical history.

It is preferable for the practice to use nationally recognised coding systems rather than a system which is idiosyncratic to the practice. Coding does not necessarily need to replace details in past medical histories that have been recorded in free text. It should be seen as a useful adjunct to a comprehensive past medical history. Certain aspects of a person’s past medical history may be difficult to formally code and yet remain important information for that particular patient.

Services providing care outside normal opening hours

Services that provide care outside normal opening hours are exempt from Indicator B since in general they do not have active patients as defined in these Standards and do not provide continuity of care for patients. However, health summaries produced by services that provide care outside normal opening hours should contain, as a minimum, sufficient relevant information for the GP to provide safe and effective care. Copies of such summaries should be provided to the patient’s regular GP.

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 1.7.2

Health summaries

Our practice incorporates health summaries into active patient health records.

In a nutshell

Health summaries are concise, up-to-date reports included in active patient health records that allow clinical staff to provide safe, quality patient care. Health summaries contain core health information – such as known allergies, adverse drug reactions, current medications, current health problems, immunisations, relevant past health history, health risk factors and relevant family or social history – to enable safe and relevant clinical care, even if that care is provided by a clinician who is not the patients’ usual clinician.

Key team members

  • Clinical staff
  • Health service manager

Key organisational functions

  • Patient health records policy
  • Patient confidentiality and privacy policy
  • Patient communications policy

Indicators and what they mean

Table 1.15 explains each of the indicators for this criterion. Refer to Criterion 1.7.2 Health summaries of the Standards for general practices for explanations of some of the concepts referred to in this criterion.

Table 1.15 Criterion 1.7.2 Health summaries
IndicatorWhat this means and handy hints
▶ A. Our practice can demonstrate that at least 90% of our active patient health records contain a record of known allergies. It is important that known allergies are recorded for each individual patient, and this indicator requires you do this for at least 90% of active patient health records. Where no allergy is known, it is important to record ‘no known allergies’ in the health records to indicate it has been checked with the patient. Demonstrating this indicator could mean asking the question during regular patient information collection points, and recording the response on the new patient health record sheet and in the health summary sheet. Prompting doctors and other clinical staff to ask about allergies via the electronic health record system is also effective.
▶ B. Our practice can demonstrate that at least 75% of our active patient health records contain a current health summary. A satisfactory summary includes, where appropriate:
  • adverse drug reactions
  • current medicines list
  • current health problems
  • relevant past health history
  • health risk factors (e.g. smoking, nutrition, alcohol and physical activity)
  • immunisations
  • relevant family history
  • relevant social history including cultural background where clinically relevant.
When a member of your clinical team consults with patients, information about the consultation should be recorded in the consultation notes, and updated in the health summary, especially for active patient health records. This includes information about social and family circumstances.

Because of the impact that recent life events (such as a death) and other circumstances or events (such as housing, employment) may have on the health of Aboriginal and Torres Strait Islander patients, this information could also be recorded in the health summary.

The RACGP recognises that specialist health services such as ACCHSs have a team of clinical and other staff responsible for the care of patients, rather than just the GP. Where this occurs, patient interactions between those staff members need to be recorded in patient health records as soon as practicable after the consultation or visit.
C. Our practice has documented standardised clinical terminology (such as coding) which the practice team uses to enable data collection for review of clinical practice. Coding provides a standardised means of recording information. This is particularly important for commonly used clinical terminology.

It is preferable that your health service adopts a nationally recognised coding system so that visiting clinical staff, locum staff and out-of-hours service providers can easily understand the information. The use of consistent terminology is especially important for chronic disease registers and for clinical audits that drive quality improvement. It also leaves little room for error or guessing by other clinical staff members when they consult with patients or read patient health records.

Coding should be used to complement other important information, rather than to replace it all. Where detailed health and other information is required, it should be recorded so that context, details and clinically significant information can be easily understood. Excessive use of coding may be more confusing and unnecessary in these instances.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure there is sufficient information in the health records of 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.

If a patient has an allergy, the type of reaction is also documented; for example, anaphylaxis, swelling, rash or nausea. Patients who do not suffer from allergies have their health file marked with ‘no known allergies’, so other staff members know that those patients have been asked if they have any allergies. This is because if the allergy section is left blank it could be incorrectly assumed that either the question has not been asked or that the patient does not have any allergies.

The health summary section in patient health records contains information on adverse drug reactions as well as patients’ health risk factors such as smoking status, nutrition, alcohol consumption and physical activity, as well as any relevant family history. There are some communities whose members do not disclose relevant family history; in these cases it is documented in the patient health file that relevant family history was asked and the patient chose not to disclose. This way it is not assumed by other health providers that the question has not been asked, so that the patient is not continually asked questions on family history.

The health summary section in patient health records contains information on a patient’s relevant social history, including cultural background. This may include type of employment, if any (many jobs may expose a person to potential health hazards, and lack of employment or under-employment can be stressful), and environmental factors such as housing, cooking facilities and access to fresh food and clean water, shopping facilities and transport. There are some communities whose members do not disclose relevant social history; in these cases it is documented in the patient health file that relevant social history was asked and the patient chose not to disclose. This way it is not assumed by other health providers that the question has not been asked, so the patient is not continually asked questions on social history.

Health workers and nursing staff routinely undertake health assessments of patients and record their allergy status, adverse drug reactions, current medicines, past history, social history, family history, risk factors and relevant cultural history in the patient consultation notes. This information forms the basis of an up-to-date health summary.

If a patient does not wish to discuss their clinical, family or social history with a staff member an entry is made in the file in the relevant area noting that the patient chose not to disclose. This ensures it is documented that the information was requested, so that when file audits are conducted it is clear that staff are endeavouring to cover all areas of a full history.

The staff induction covers the service’s clinical software program and its policy relating to the use of coding contained within the clinical software program. The practice of free texting within the fields of the software program is actively discouraged. Clinical staff members are encouraged to document within the consultation notes more complex histories or diagnosis options that do not fall within the generic coding fields. The service actively contributes to chronic disease registers and participates in clinical audits, using the coding system.

A 3-monthly audit and data cleansing is performed prior to running reports and data extraction.

Showing how you meet Criterion 1.7.2

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.

  • Conduct an audit of patient health records.
  • Conduct data cleansing of clinical software programs.
  • Ensure and show that staff induction covers use of clinical software and documentation protocols such as recording ‘no known allergies’, or ‘patient does not wish to disclose family history’.
  • Maintain a policy and procedure manual.
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