Attributes of high-quality health records

High-quality health records have six features. They are:

• Accurate – correctly reflects the patients details, information captured in consultation, and information collected from other sources.
• Complete – contains sufficient information, keeping in mind the ‘expect to share’ principle
• Consistent – uses a recognised medical vocabulary, standardised terms and abbreviations
• Legible – easily read and understood; written in a way that is meaningful to other users
• Accessible – data is recorded in ways that make it readily retrievable
• Up-to-date – updated in a timely manner.