The RACGP is proud to launch a new resource for primary healthcare professionals, Quality Health Records in Australian Primary Healthcare: a Guide (the Guide).
The Guide, developed in consultation with colleagues across the Australian primary healthcare sector sets out common expectations on quality health records – inarguably the cornerstone of safe, quality healthcare in the 21st century.
RACGP President Dr Liz Marles said, “Until now, there has been no single document setting out common expectations on quality health records in Australian primary healthcare.”
“To achieve safe and effective continuity of care and optimal health outcomes for the Australian community, health professionals should ensure the information they record in health records is complete, consistent, legible, accurate, relevant, accessible and timely.”
The Guide provides a foundation resource for health professionals to produce, manage and use high quality health records that are fit for a range of purposes including safe clinical decision making, good communication with other health professionals, trustworthy partnerships with patients and effective continuity of patient care.
“Quality health records cannot be underestimated in an environment where GP-led multidisciplinary care is recognised as best practice in achieving the best possible patient outcomes,” Dr Marles said.
“The increasing emphasis on the e-health space is also a factor that reinforces the importance of high quality health records, as electronic formats become increasingly commonplace and the sharing of patient-approved health records is encouraged,” Dr Marles said.
The Guide covers electronic, paper-based and hybrid health record systems, and in each section describes core principles, tips for compliance and clinical examples to illustrate application in day-to-day clinical practice.
The Guide is a user-friendly source of information and is not designed to impose new professional obligations over and above recognised best practice.