Criterion 1.7.2 Health summaries
Our health service incorporates health summaries into active patient health records.
► A. At least 90% of our active patient health records contain a record of allergies in the health summary (health records review).
► B. At least 75% of our active patient health records contain a health summary. A satisfactory summary includes where appropriate (health records review):
- adverse medicines events
- current medicines list
- current health problems
- past health history
- risk factors
- relevant family history
- relevant social history.
► C. Our patient health records show evidence that health summaries are updated to reflect recent important life events (health records review).
► D. If our health service uses both an electronic and paper based system for recording a patient’s health summary, our service can demonstrate how the patient’s health information is accessible when required (interview).
A vital component of a quality health record is a health summary. All active records should contain an up-to-date health summary. A good health summary assists GPs, nurses, other doctors, allied health staff and other members of the clinical team in the health service to obtain an accurate overview of all the components of a patient’s care. Health summaries reduce the risk of inappropriate management including medicine interactions and side effects (particularly when known allergies are recorded). Health summaries provide the social and family overview vital to patient centred care. A health summary will assist with health promotion by highlighting lifestyle problems and risk factors (eg. smoking, alcohol, nutrition, physical activity status). Health summaries also help disease prevention by tracking immunisation and other preventive measures.
An up-to-date health summary is critical for the smooth transfer of care from one practitioner to another (either within the health service or at another prison or community based service). Because health summaries are such an important component of safe, high quality care, the requirement that at least 75% of all patient health records contain a health summary has been included in these Standards.
While it is important to record all known allergies in health summaries, it is particularly important to record known allergies to medicines as this facilitates safer prescribing and reduces the likelihood of adverse patient outcomes. If a patient has no known allergies, it is important to record this and not leave it as an assumption in the absence of recorded allergies.
While a health summary would normally include a list of current medicines, in general, subject to the patient’s consent, it is advisable for a medical practitioner to confirm medications prescribed by a colleague in the community before the medications are prescribed again within the prison setting.
Recording recent important life events covers a wide range of social events of importance to the patient, which may include changes in accommodation, family structure (eg. death of family members) and/or important events relating to the person’s incarceration. Recent important life events can alter a patient’s preferences, values and the context of their care.
Where a health service does not meet the 75% minimum level in one or more of the elements of a health summary (eg. risk factors), the health service needs to explain how it is attempting to improve the completeness of the health summary in regards to that element. A health service that shows a deficiency in the recording of any information needs to have a plan for improvement.
This criterion applies to active patient health records only. In the case of health services in prisons, an active health record is the record of a patient who is currently incarcerated in the prison.
The RACGP appreciates that family and social history especially should only be recorded in a health summary where it assists with patient care and does not impair a patient’s right to privacy and, as such, not all health summaries will include all the items listed in Indicator B. Recording details of a patient’s criminal history should only be included in a health record where it is required for facilitating patient care or maintaining the safety of health service staff.