Putting quality into practice

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).

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.

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).