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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 1.7.3

Consultation notes

Each of our patient health records contains sufficient information about each consultation to allow another member of our clinical team to safely and effectively carry on the management of the patient.

Indicators

▶ A. Our patient health records document consultations including consultations outside normal opening hours, home or other visits and telephone or electronic communications where clinically significant, comprising:

  • date of consultation
  • patient reason for consultation
  • relevant clinical findings
  • diagnosis
  • recommended management plan and, where appropriate, expected process of review
  • any medicines prescribed for the patient (including name, strength, directions for use/dose frequency, number of repeats and date medicine started/ceased/changed)
  • complementary medicines used by the patient
  • any relevant preventive care undertaken
  • any referral to other healthcare providers or health services
  • any special advice or other instructions
  • who conducted the consultation (eg. by initial in the notes, or audit trail in an electronic record).

▶ B. Our patient health records show evidence that problems raised in previous consultations are followed up.

▶ C. Our practice can demonstrate that we are working toward recording preventive care status (eg. currency of immunisation, smoking, nutrition, alcohol, physical activity, blood pressure, height and weight [body mass index]).

Explanation

Key points

  • Patient health records should be legible and understandable by another GP or clinical staff member to facilitate safe and effective care
  • Complementary medicine consumption by patients should be documented to minimise drug interactions
  • Patient health records should be updated as soon as practicable at or after consultations and visits. The records should identify the person in the clinical team making the entry.

Consultation notes are important for safe and high quality care

A consultation in general practice is the entry point to the healthcare system for most Australians. A consultation is an interaction between the practice and the patient related to the patient’s health issues.

A consultation may be with a GP, nurse or other staff member who provides clinical care within the practice.

The quality of patient health information needs to be such that another GP or clinical staff member could read and understand the terminology and abbreviations used, and, from the information provided, be equipped to manage the care of the patient.

Ideally, information about the consultation needs to be entered into the patient health record as soon as is practical at the time of the consultation, or as soon as information (eg. results) becomes available.

Many people now take complementary and over-the-counter medicines which may react adversely with conventional medicines. Therefore, complementary medicines prescribed by a member of the clinical team or self reported by a patient need to be documented in the same manner as other medicines.

As part of risk assessment, practices are encouraged to routinely record patients’ height, weight and blood pressure at intervals of their choosing. This is useful in children to assess normal growth or failure to thrive and also to document weight loss and gain over a period of time in all age groups as this may be an indicator of disease.

As part of the continuing care that GPs provide, information concerning patients is gathered over more than one consultation. It is important there is a connecting process so that information about clinically significant, separate events in a patient’s life and in the care provided are not overlooked, but are recorded and managed in a way that makes this information readily accessible. Regularly updated health summaries are one method of managing this information. Clinically significant information may include the patient’s health needs and goals, preventive health activities, medical condition(s), preferences and values. All this contributes to care that is responsive to patient needs.

Consultation notes are a risk management tool

Medical defence organisations have identified lapses in following up on problems and issues raised previously by patients as a considerable risk. This can occur when patients are not seen by their usual GP, although it can also occur when a GP is busy or distracted. Thus, for high quality patient care, it is useful for general practices to have systems that reduce the risk of such lapses.

Coding

Consistent coding of diagnoses, when available, should be used in the consultation notes to support continuous quality improvement of clinical care and patient outcomes.

Services providing care outside normal opening hours

Consultation notes 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 notes 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 1.7.3

Consultation notes

Each of our patient health records contains sufficient information about each consultation to allow another member of our clinical team to safely and effectively carry on the management of the patient.

In a nutshell

Sufficient, legible and easy-to-understand consultation notes provide crucial information for the safety and quality of ongoing patient care.

Key team members

  • Clinical staff

Key organisational functions

  • Patient confidentiality and privacy policy
  • Patient communications policy

Indicators and what they mean

Table 1.16 explains each of the indicators for this criterion. Refer to Criterion 1.7.3 Consultation notes of the Standards for general practices for explanations of some of the concepts referred to in this criterion. 

Table 1.16 Criterion 1.7.3 Consultation notes
IndicatorWhat this means and handy hints
▶ A. Our patient health records document consultations including consultations outside normal opening hours, home or other visits and telephone or electronic communications where clinically significant, comprising:
  • date of consultation
  • patient reason for consultation
  • relevant clinical findings
  • diagnosis
  • recommended management plan and, where appropriate, expected process of review
  • any medicines prescribed for the patient (including name, strength, directions for use/dose frequency, number of repeats and date medicine started/ceased/changed)
  • complementary medicines used by the patient
  • any relevant preventative care undertaken
  • any referral to other healthcare providers or health services
  • any special advice or other instructions
  • who conducted the consultation (e.g. by initial in the notes, or audit trail in an electronic health record).
Patient health records should contain consultation information that your health service collects about the relevant patient, including the information identified in Indicator A. This includes consultations by your health service’s GPs, home visits (where available), out-of-hours consultations, telephone conversations and other electronic communications that are clinically significant.

Similar information should be recorded by other clinical staff who consult or interact with patients (such as nurses or Aboriginal health workers).

It is recommended that consultation notes are recorded as soon as practicable after consultations and visits/interactions.
▶ B. Our patient health records show evidence that problems raised in previous consultations are followed up. Consultation notes should of themselves provide a trail of healthcare given to individual patients. They should identify where problems raised in a consultation need to be followed up, and record that they were followed up. Health records themselves are vital ways of ensuring this happens.

It is recommended that follow-up notes are built into the consultation or record sheet to alert other clinical staff of the need for follow-up; examples include flags in electronic records, or coding in a special column on the sheet. It is recommended that you consider a system of identifying and actioning follow-up procedures to minimise risks in failure to follow-up.
▶ C. Our practice can demonstrate that we are working toward recording preventive care status (e.g. currency of immunisation, smoking, nutrition, alcohol, physical activity, blood pressure, height and weight [body mass index]). As part of your preventive care processes, it is recommended that you develop a routine procedure for gathering general health information from patients on a regular basis. Routinely gathering information such as patients’ height, weight and blood pressure assists in the early detection of health risks and diseases.

This indicator is particularly important for ACCHSs, because of the higher incidence of a number of chronic diseases in Aboriginal and Torres Strait Islander populations. The development of resources such as the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people significantly enhance this process.

Clinically significant information such as patients’ health needs and goals, preventive health activities, medical conditions, preferences and values all contribute to determining clinical care approaches that are responsive to patient needs.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can ensure effective consultation notes are maintained 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.

The health service’s patient health files contain clear and accurate information about who performed the consultation, the date of consultation and the reason for consultation, as well as a history and review of medication including any over-the-counter medication taken by the patient. The files also include clear and accurate information about examinations, observations, diagnoses or provisional diagnoses, tests or investigations ordered, a plan of management, any medication prescribed, referrals to internal and external health providers, advice or special instructions and any planned review or follow-up.

The health service’s policy and procedure manual documents the activities to be undertaken when screening a patient. These include blood pressure, blood sugar level, height, weight, history and review of immunisations.

The service’s clinical software program contains proforma health assessment templates for patients of varying ages that at a minimum meet the Medicare Benefits Schedule requirements.

The staff member responsible for scanning paper-based correspondence into the electronic patient health file undertakes random monthly audits to check that scanned information can be easily read. If it appears that the quality of the scanned documents is poor, advice is sought from the service’s information technology provider.

Showing how you meet Criterion 1.7.3

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 a policy and procedure manual.
  • Conduct an audit of patient health records.
  • Keep Medicare billing records.
  • Keep an appointment book.
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