Health records should contain sufficient information to reliably serve a range of purposes.
Health records can have a range of purposes (Box 1), and health records should contain adequate information to serve those purposes. This includes information collected by the practice and information from other sources (Box 2).
GPs should consider the many different purposes of health records when recording information during a consultation, keeping in mind the ‘expect to share’ principle (refer to Why quality matters section).
At a minimum, the RACGP’s Standards for general practices (5th edition) require patient health records to contain:
- (for active patients) identification details, contact details, demographic information, next of kin, emergency contact information
- records of consultations and clinical-related communications
- evidence that matters raised in previous consultations are followed up
- Aboriginal and Torres Strait Islander status
- cultural backgrounds of patient (if relevant)
- lifestyle risk factors
- date of consultation
- who conducted the consultation
- method of communication (eg physical, teleconference)
- patient’s reason for the consultation
- relevant clinical findings
- any allergies
- diagnosis, if appropriate
- a recommended management plan and, where appropriate, the expected review process
- any medicines prescribed (including name, strength, directions for use, dose, frequency, number of repeats and date the patient started/ceased/changed the medication)
- patient consent for presence of a third party, if applicable (eg a medical student)
- record of any patient emails received
- documentation of referrals
Other information health records might contain includes paper notes, applicationbased measurements (eg blood pressure, weight, glucose readings), complementary or over-the-counter medicines a patient is taking, advanced care plans, immunisations and occasional medication administration (eg monthly depot injections, vitamin B12, implants).
More about the required content of patient health records can be found in Core Standard 7 of the RACGP Standards for general practices (5th edition).
C7.1A Our practice has an individual patient health record for each patient, which contains all health information held by our practice about that patient.
- maintain individual health records for each patient that include all required information.
C7.1B Our active patient health records contain, for each active patient, their identification details, contact details, demographic, next of kin, and emergency contact information.
- include, for each active patient, all of the required information listed in the Indicator.
C7.1C Our patient health records include records of consultations and clinical-related communications.
- ensure consultation notes include all mandatory elements • include a record of all clinical-related communications (including emails) in the patient’s health record.
C7.1D Our patient health records show that matters raised in previous consultations are followed up.
- document matters that have been followed up in the patient health record.
C7.1E Our practice routinely records the Aboriginal or Torres Strait Islander status of our patients in their patient health record.
- document the patient’s Aboriginal or Torres Strait Islander status in patient health records.
C7.1F Our practice routinely records the cultural backgrounds of our patients in their patient health record.
C7.1G Our patient health records contain, for each active patient, lifestyle risk factors.
- document information relating to lifestyle risk factors such as height, weight and blood pressure in the patient health record.
C2.1C Our practice acknowledges a patient’s right to seek other clinical options.
- keep documentation of a patient’s decision to seek another clinical opinion in the patient’s health record
- keep appropriate documentation of referrals in the patient’s health record.
Tips for maintaining complete records
Box 2. Managing information from other sources
General practices receive a large volume of patient health information from external sources, often in a range of formats (eg pathology results, correspondence from specialists or allied health providers, hospital discharge summaries, significant telephone communications, photos, video recordings).
To ensure information is reviewed and correctly incorporated into health records, practices should implement a system for managing information from other sources. This system should support patient confidentiality, continuity of care and safe clinical handover. It might include:
- making particular team members responsible for receiving and managing information from other sources
- having clear procedures for incorporating information into health records (eg when and how to scan information into records)
- allowing clinicians time in their schedules for reviewing and incorporating incoming clinical information into records
- using secure messaging to receive health information electronically
- reviewing the process regularly to ensure information is being incorporated correctly
- Use patient registration forms (electronic or paper), so that required information is routinely captured.
- Develop policies and checklists for the procedures involved in managing health information, both from within the practice and from other sources. For example, it could be practice policy that if new patient registration forms are returned incomplete, or not entered into the clinical information system, it is the role of practice staff to follow up with either the patient or their GP to complete the form and enter the information in the system.
- Record information that you would find helpful. Think of a locum GP using your health records: could they use the records to manage unfamiliar patients safely, effectively and efficiently?