Improving health record quality in general practice is designed to help general practices produce and maintain high-quality health records that are fit for purpose. The guide presents six attributes of high-quality health records, and provides guidance about how practices can achieve these, including how to set up a health record system that facilitates the production of high-quality health records.
Tips and case studies are included throughout to give practical information about how to apply the principles discussed.
The attributes of health records presented in this guide align with the Medical Board of Australia’s code of conduct for Australian doctors regarding medical records (section 8.4). It should be noted that this guide does not impose new obligations over the current RACGP Standards for general practices. Where a recommendation relates directly to a standard or ‘Indicator’, this is highlighted in the text.
The guide is general in nature and should be applied in the context of existing legislation, charters, codes of conduct, professional standards, clinical guidelines, or policies and position statements relevant to particular disciplines and organisations within the Australian primary healthcare sector.
Where there is a ‘must have’ in the Standards for general practices (5th edition), we direct you to the relevant Indicator for each section. Recommendations are provided to assist general practices to meet the required accreditation standards.
Sharing health information
Although issues of privacy and confidentiality lie outside the immediate scope of this guide, they are nevertheless fundamental to what GPs need to consider before sharing health information with others, including other health professionals, patients and specified third parties.
In all instances where the guide refers to the ‘sharing’ of health information, this is intended to cover:
- the appropriate use and disclosure of information by a GP, including circumstances where use or disclosure is required or authorised by law (eg where a GP may need to use or disclose information to lessen or prevent serious threats to life, health or safety)
- a patient’s consent – whether express or implied – to the collection, use and disclosure of health information
- a patient’s right to access their own health information, including circumstances where denying access is required or authorised by or under law (eg where access to the information would pose a serious threat to the life or health of any individual).