Improving health record quality in general practice

Introduction

Health Record data quality


 

The quality of patient health records kept by general practices is an important factor in safe and effective healthcare.

The primary purpose of a clinical health record is to hold the information about a patient that is required for effective care: good patient information supports appropriate clinical decisions. With changes to the way primary care is delivered, including increasing use of shared care models and the introduction of a national eHealth record (My Health Record), the quality of this information is more important than ever. No longer serving only individual general practitioners (GPs) or practices, information in a patient’s health record is likely to be shared between and relied upon by primary, secondary and tertiary healthcare services.

Aside from contributing to effective, safe and personalised patient care, general practice health records may also serve a number of other purposes, including providing data for research and policy, contributing to education, and providing healthcare evidence for medicolegal purposes. All these uses depend on records containing high-quality information that is accessible to appropriate users.

Yet maintaining high-quality health records is not always regarded as a priority by general practices or GPs. Competing demands on busy clinicians and practice staff mean the importance of health record quality is often overlooked, and some may not be aware of what is expected of health records.

To assist with this, The Royal Australian College of General Practitioners (RACGP) has produced this guide, outlining what constitutes a highquality health record and how practices can put systems in place to ensure they produce health records that are fit for purpose.

Benefits of high-quality health records

Maintaining high-quality health records has benefits for patients, GPs, the practice and the wider community.

For patients, the quality of their health information kept by a practice can affect their healthcare outcomes, as it informs decisions about their treatment and facilitates continuity of care (both within the practice and between other services). High-quality records also make it easier for patients to access and understand their healthcare information.

For individual GPs, high-quality health records allow them to effectively communicate with their colleagues and other health professionals. They allow GPs to take full advantage of clinical information systems to more efficiently manage patient follow-up – through reminders or recalls – for particular patient populations. GPs may also rely on health records in defending against medico-legal claims.

For general practices, high-quality patient health data is becoming more and more essential for quality improvement activities – whether this be carried out by a practice itself or in collaboration with an external agency (eg participation in NPS MedicineWise’s MedicineInsight program). It also allows a practice to better understand and identify its own patient cohort. This supports more effective healthcare delivery at both an individual and local population level.