Improving health record quality in general practice

Practice tips for improving health record quality

Improving health record quality in general practice
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Improving or maintaining the quality of health records does take effort, and it requires a continuous, practice-wide approach. Although there are no ‘quick fixes’, focusing on everyday areas of practice such as the following will help improve the quality of health records.

  • Educate the practice team about the importance of high-quality health records and how to produce and maintain them.
  • Designate a practice champion for highquality health records who leads by example. Allow them dedicated time to fulfil this role.
  • Promote an ‘expect to share’ mindset among staff.
  • Educate, train and support all team members responsible for managing patient information.
  • Provide access to education and training about how to use the clinical information system and get the most out of it for maintaining health records.
  • Make sure everyone in the practice knows where to obtain support for the clinical information system and software.
  • Provide tip sheets and trouble-shooting guides for common problems with the practice’s clinical information system.
  • Make the quality of health records a regular focus of practice team meetings. For example:
    • acknowledge or reward GPs who keep high-quality health records
    • in multidisciplinary practices, organise a meeting to agree on standardised terminology across disciplines
    • make the quality of the patient’s health record one of the standard areas to focus on when the practice team conducts case reviews.
  • Allow time for the practice team to update their patients’ records. For example, if required, provide brief gaps in daily appointment schedules for GPs to complete consultation notes.
  • Consider what tools would help staff keep high-quality health records: checklists, standardised forms, proper equipment, software add-ons such as clinical audit tools or data analysis software.
  • Conduct regular audits of the quality of health records, measuring them against the attributes described above.
  • Implement a feedback process regarding health records to address problems raised by other healthcare professionals, other services or patients.
  • Keep track of near misses and mistakes in the incorporation of information from other sources to identify ways to prevent these “ happening again.
It can be hard to maintain high‑quality records, and it requires effort. I think the whole process must be iterative, a continuing cycle of improvement.
– Member, RACGP Expert Committee – eHealth and Practice Systems
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