Criterion 1.7.1 Patient health records
For each patient we have an individual patient health record containing all clinical information held by our health service relating to that patient.
► A. There is evidence that each patient has an individual patient health record that contains all the health information held by our health service relating to that patient (health records review).
► B. Our patient health records are legible (health records review).
► C. Our active patient health records include (health records review):
- the patient’s full name
- date of birth
► D. Our health service can demonstrate that we are working toward recording the following information in our active patient health records (health records review):
- cultural background (eg. Aboriginal and Torres Strait Islander status)
- the person the patient would like contacted in an emergency.
Health services need to have an effective system whereby an individual patient’s health information is stored in a dedicated patient health record. Health records need to include:
- the patient’s contact details, name, date of birth and other demographic information
- medical history (including current medications)
- social history, family history
- consultation notes (including any care outside the normal opening hours of the health service and visits to a patient’s living quarters)
- 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 relevant legal reports.
Medical errors and breaches of personal privacy can occur as the result of information being recorded in, or taken from, an incorrect patient health record. As a result, it is important to have an accepted protocol for ordering given and family names, as well as ways of distinguishing the files of patients that have similar or identical names.
For health services in prisons, a patient’s health record needs to be independent and separate from that person’s correctional record. The patient’s health information should remain private and confidential as outlined in section 2.42 of the Standard guidelines for corrections in Australia35 (see Criterion 4.2.1: Confidentiality and privacy of health information).
Patient health records may be solely electronic, solely paper based, or a hybrid (combination of paper and electronic records). If health information about a patient is kept in two sites (as in the case of hybrid records), health services need to have a system in place to ensure all the information is available and accessible when needed. This is important to ensure continuous and comprehensive care especially when a patient is relocated to another prison or to a community based practitioner (see Criterion 1.5.1: Continuity of comprehensive care).
Basic personal information that is required from each patient might be collected by health service staff, with new patients completing a generic form or being interviewed in a private environment before their consultation.
It is critical that patient health records are legible so that any other member of the health service team could take over the care of the patient if necessary. If the health service scans documents such as external reports for inclusion in a patient’s health record, the scanned copy needs to be of quality that reproduces the legibility of the original document.
Health services also need to be working toward routinely recording the person the patient would like contacted in an emergency, and the patient’s cultural background. Health services that have not been routinely recording this information already need to demonstrate how they are improving the consistency with which it is recorded in patient health records (see www.racgp.org.au/standards/fourthedition/factsheets).