The quality of patient health records is an important factor in the provision of safe and effective healthcare
Maintaining good quality patient health records supports appropriate clinical decision making and continuity of care, especially with the increasing use of shared care models and the introduction of a national eHealth record (My Health Record).
Further, the maintenance of quality health records in general practice contributes to data provision for research and policy, education and medico-legal purposes.
To assist with the maintenance of high-quality health records, the RACGP has produced this guide, outlining what constitutes a high-quality health record and how practices can put systems in place to ensure they produce health records that are fit for purpose.
Health Record data quality
Health record data quality
Trina: So the reason we need good, clean, health data and good records on our patients are not only just for local reasons, but for sharing reasons as well. Locally we need good records because we use our data for clinical decision support. So if the data isn't coded or isn't accurate or up-to-date we miss out on those decision-support safety networks. I think it's respectful to other people as well because you're not the only person in your practice that's going to be using that patient’s records. There's other GPs, and the nurse, and you might have locums when you go on holiday… So it's respectful to the patient and to the other care providers to make sure that your notes are useful and clean and up to date.
We use our practice for population health as well, so if the information is not there then you can't do population health in your practice. And more and more we're sharing information about our patients with other providers, to different organizations, to shared health records to various different providers. So the information needs to be useful to make their job as easy [as possible] and deliver the safest health care they can for the patient to. So we also try and foster a culture within our practice of respect of the patients and respects of the other providers. So it's because I respect you as another GP or because I respect my practice nurse - I want them to work off the best quality data that I can provide for them If they're seeing a patient that I've seen. It’s also respect for the patients as well because they trust us with our information, so we really have a duty of care to keep it current and clean and accurate.
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In summary, you must not edit or adapt it or use it for any commercial purposes.
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