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RACGP aged care clinical guide (Silver Book)

Silver Book - Part B

Medical records at residential aged care facilities

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Last revised: 18 Dec 2019

  • There are generally three models under which general practitioners (GPs) work at residential aged care facilities (RACFs) – solo practitioner, practice-based practitioner and aged care–specific practitioner.
  • Medical records in RACFs should follow the fifth edition of The Royal Australian College of General Practitioners’ (RACGP’s) Standards for general practices.
  • A GP or the general practice is responsible for clinical records.
  • Sharing notes with RACFs is complex and challenging, but communication between the general practice and RACF is vital.
  • Writing notes in the RACF file, printing patient notes or copying and pasting clinical notes into the RACF patient file are methods to share notes and clinical information.

Medical records at residential aged care facilities (RACFs) are managed differently depending on the system within which the general practitioner (GP) works.

There are generally three models under which GPs work at an RACF – solo practitioner, practice-based practitioner and aged care–specific practitioner – each with its own challenges in maintaining patients’ medical records.

Solo practitioner

The GP may decide to start working at RACFs of their own accord. Commonly known as ‘working out of the boot of their car’, this method allows for flexibility and self-management.

The advantage of this system is the autonomy of practice, where the GP is free to manage their systems, schedule and work as they wish. However, the main disadvantage is that the GP is responsible for managing the ‘back office’ logistics of their practice. Maintaining accreditation under The Royal Australian College of General Practitioners’ (RACGP’s) Standards of general practices (Standards) is part of these logistics, which can be challenging.

Practice-based practitioner

Many GPs visit RACFs via their ‘regular’ bricks-and-mortar general practice, and doing so on an ad hoc basis is common practice. The GP visits their patients in RACFs when required, and usually does so after a ‘standard’ day in their consulting room.

This method can be tiring, and does not lend itself to proactive care of the patient in RACFs; however, it can certainly be done with care.

Allocating specific time (eg an hour, a session or a day) for undertaking aged care work is a better method of managing RACF residents. The RACF is therefore aware that the GP comes at that time, and acute issues are managed accordingly. Chronic care is scheduled in, and the GP is able to attend to proactive care.

The advantage of visiting RACFs as a practice-based practitioner is that all of the GP’s patient notes are in the one place, and they have the support of the back office of their regular practice.

The disadvantage is that the system may not be completely set up to manage RACF residents; for example, the electronic health records may not be accessible remotely.

Aged-care specific practitioner

Aged care–specific general practices have recently been established to support GPs in their aged care work. GPs who want to dedicate time to aged care work but find that their regular practice is not set up to support them can use these services.

The advantage of using an aged care–specific general practice is that they are fully set up to support the GP in aged care work.

The disadvantage is that the GP’s work can be fragmented between two practices.

It is vital to ensure that whichever practice system is used, the standards for maintaining medical records are upheld.

The RACGP’s Standards notes that this is vital in RACFs:1

  • Our practice has a system to manage our patient’s health information.
  • If our practice is using a hybrid patient health record system, a note of each consultation/interaction is made in each system, and that record includes where the clinical notes are recorded.

The RACGP’s Standards recommends electronic health records rather than hybrid records. The advantage of electronic health records is that they are more prominent in the RACF setting. There is more chance of paper-based notes becoming misplaced because the GP is constantly moving from one location to another.

It is also the responsibility of the GP to manage an RACF patient’s preventive and proactive care. The reminders and recall systems of the electronic health records lend themselves to supporting these aspects of clinical care.

The ideal setting would be for the GP to have remote access to the practice’s electronic health record to allow them to write notes at the facility directly after they have seen the patient.

According to Criteria C6.2 of the RACGP’s Standards, the GP needs to have access to the patient’s health information, when needed.

The practice needs to maintain control of patient medical notes, and one of the key challenges to working in an RACF is the sharing of information. One solution to this problem is to copy and paste medical notes from the GP’s electronic health record into the RACF’s software.

It is the GP’s responsibility to ensure that the information copied into the RACF’s notes is relevant to caring for the patient, but does not contain any confidential information. The copy and paste method works if the GP has access to their electronic health record remotely.

Another solution would be to print out the patient’s notes that are generated on the day (most electronic health records should have this feature available). Yet another option would be to write handover notes into the RACF’s software or paper-based patient notes. It is obviously suboptimal to ‘double write’ notes, but sometimes it is necessary.

It is vital to ensure that the GP is maintaining their own patient notes as it is not adequate for a GP to solely use the RACF’s systems as their medical notes. Notes in the RACF’s systems are not under the control of the GP and the practice, and do not allow for clinical governance and proactive medical care.

It is important that RACF staff have access to the GP’s instructions and decisions. A common way to do this is to give the RACF a copy of the clinical notes. There are multiple ways to do this, but all of these have their problems. Despite this redundancy, it is vital for patient care that the RACF staff is aware of the doctor’s decisions and instructions.

Printing out the doctor’s notes and leaving them with the RACF is a manageable option. It requires that notes are written in the electronic medical records, and that there is access to a printer; however, some RACFs have their own electronic records and prefer electronic notes. Printing the notes back at the general practice and faxing them through to the RACF is another way achieve this.

Copying and pasting from the practice records to the RACF records is another way to share notes. This requires access to the practice’s electronic medical records on the RACF computer or access to the RACF records on the practice’s computers.

Writing ‘hand-over’ notes on the RACF systems is a third option. In this case, the GP does not need to write extensive notes to the RACF, but rather brief instruction notes that contain all relevant information.

The sharing of notes is one of the challenges of working in RACFs. It is a space where innovation is occurring and new solutions to the problem will arise as time passes. There is some hope that My Health Record will contribute to the solution.