A health record ‘system’ refers to the way health information is collected, recorded and stored in a practice. The system encompasses the clinical information software and how it is used.
High-quality health records depend on a health record system with the right capabilities and capacity for the practice. The use of this system needs to be supported by practice policies and procedures, and by appropriate education and training. It is recommended that practices ensure they have adequate support to implement and oversee operation of electronic health record systems.
Practices may wish to designate a team member to manage the practice’s strategy for health records. This role might include maintaining policies and procedures, and coordinating staff education and training; however, it is up to practice management to promote a practice culture that values highquality health records (Box 4).
Box 4. The importance of leadership and culture
A key part of a practice’s record-keeping system are the people who use it. For effective health record keeping to be prioritised, it must become part of routine practice; to become routine, it must be valued by the whole practice team.
The importance of a team culture that promotes high-quality health records cannot be underestimated. This may take time to develop, and it requires strong leadership that supports the practice team. Ongoing education and workplace policies and systems should facilitate high-quality health record keeping.