Improving health record quality in general practice

Putting quality into practice

Last revised: 05 Dec 2023

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.

Practices could develop policies and procedures for the following aspects of high-quality health record management:

  • using the health record system
  • managing risk in the health record system (eg ensuring information is entered into correct records)
  • system security – refer to the RACGP’s Information security in general practice for more information regarding the accepted standards for information security.
  • handling health record information  (eg for entering information from outside sources and exporting patient information).

All policies and procedures should be documented, and reviewed regularly to make sure the health record system is being used as effectively as possible. Practices could also consider reviewing the team’s compliance with practice policies; for example, having the practice team search and report on inconsistent use of diagnosis codes across health records at regular team meetings.

Quick quality checks: Using software features to review health records

Most clinical information systems have features that can help you audit the quality of health records; for example, the ability to track follow-up requests, such as recalls and reminders, that have not been actioned. It may also be possible to run a report of records that contain uncoded diagnoses, which can then be updated with the proper code or term.

Education for practice team members to promote high-quality health records should begin during the induction of new members and should be ongoing from that point. This should be aimed at both clinical and administrative staff. Key areas to cover are:

  • why high-quality health records are important
  • attributes of high-quality health records
  • effective use of the practice’s health record system.

Training for GPs in the practice might include how to take advantage of clinical software features, such as decision support tools (eg asthma status for beta-blocker prescriptions, suicide risk assessment for patients with a mental health diagnosis) or automated prompts (eg for ‘reason for visit’ before a record can be closed, or regarding prescriptions that are contraindicated for a particular diagnosis).

Our practice has a comprehensive induction of all new team members, including doctors. Part of this process for clinical team members is training in the clinical software, to ensure they can use it competently, and practice protocols for health records.
– Practice manager

 Case study

As a quality improvement activity, a New South Wales general practice began auditing the quality of its patient records. Rather than conducting a one-off audit, the practice manager set up a quarterly audit, reviewing 10 records at random from each GP. She decided that reviewing specific qualities each time, such as clarity, timeliness and consistency, would let them easily compare the results of each review and assess improvement.

After three reviews, the practice manager noticed a decrease in the consistency of health information across records, with many diagnoses not being properly coded.

The practice arranged a group discussion at the next practice meeting about the importance of consistency in recording health information, and asked if there were any particular issues people were having. They realised that a quite few new GPs and locums had recently started at the practice, and these doctors were unaware that the practice had a list of standard terms. They also had not read the practice’s policy on high-quality health records.

To make sure all new GPs coming into the practice were aware of resources and policies regarding health records, it was decided to run short sessions on high-quality health records at the regular practice meetings. In addition, the list of standard terms and a health record checklist were included in the practice’s induction pack

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