Improving health record quality in general practice

What is 'quality'?

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Last revised: 05 Dec 2023

Health records are only as good as the quality of the information they contain.

Attributes of high-quality health records

Health records are only as good as the quality of the information they contain. The RACGP suggests a number of attributes of high-quality health records – that is, records that contain high-quality information that is suitable for the purposes it serves.

It should be noted these attributes are not discrete and they often overlap. For example, ensuring clinical notes are completed in a timely manner not only keeps health records up to date, it also improves their accuracy and completeness.

The RACGP suggests general practices regularly review their health records and record-keeping practices with reference to the following attributes. This can also form part of a practice’s quality improvement activities.

High-quality health records are:

Accurate

Health records should accurately and comprehensively record information captured about patients.

Accurate health information is critical to patient care. However, clinical information is by nature variable, uncertain and at times incomplete – a result of language use, the way practitioners reach a diagnosis and the variability of clinical terms used by different disciplines.

Practices and GPs therefore need to take care that records correctly reflect:

patient details, including demographic information
information captured during consultations
information collected from other sources.

Relevant indicators

C6.3D Only authorised team members can access our patient health records, prescription pads and other official documents.

You could:

maintain a policy addressing the management of patient health information.

QI3.1A Our practice monitors, identifies and reports near misses and adverse events in clinical care.

You must:

implement and maintain an incident or event register.

QI3.1B Our practice team makes improvements to our clinical risk management systems in order to prevent near misses and adverse events in clinical care.

You must:

record the actions taken in response to events recorded on the incident or event register

Tips for maintaining accurate records

Regularly check that patient contact details are up to date. For example, make it routine to confirm patient details each time they attend the practice.
Ensure only authorised and properly trained team members can access and alter patient clinical records.
Whether a consultation is in person, by telephone or conducted by other means, make sure the patient is asked to confirm their identity, and that this is matched to the correct health record before the consultation begins.
As part of your usual clinical risk management system, you may wish to record and review ‘near misses’ regarding incorrect or inaccurate incorporation of patient information into records.

Since the start of the funding program for shingles vaccine, we’ve been able to recall and vaccinate over 70% of our eligible patients. It only required a simple search using the practice software, but having accurate data made it so much easier.
- RACGP member

Complete

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).

Relevant indicators

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.

You must:

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.

You must:

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.

You must:

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.

You must:

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.

You must:

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.

You must:

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.

You must:

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.

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

Tips for maintaining complete records

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?

Consistent

The practice’s health record system should use a recognised medical vocabulary and standardised terms and abbreviations.

Using a recognised medical vocabulary and standard terms and abbreviations creates consistency when recording diagnoses, observations and procedures. This means records are usable by all health professionals who need to refer to a patient’s health record. It also allows the practice’s records to be searched for patient populations that may need additional treatment or follow-up.

Most clinical information systems will contain a nationally recognised medical vocabulary, coding system or classification system (eg SNOMED CT-AU, the World Organization of Family Doctors’ International Classification of Primary Care [ICPC]) to record patient information. These allow clinicians to use structured data entry (eg dropdown menus and pick-lists) to enter diagnoses, prescriptions, pathology and other diagnostic results. This information is automatically coded and classified by the software so that all patient records contain standardised information.

Free-text information is important for providing a narrative or context for a patient’s health information, but it is more prone to ambiguity and is difficult to search. Where possible, free text should be used as a complement to the coding system. Clinicians should be mindful of the terms they use in free text fields and whether their meaning will be clear to others who might read the record, including patients (Box 3).

To help standardise free-text fields, the health professionals within a practice might agree on standard terms – for example, where different disciplines use different terms for the same diagnosis or procedure, or where there are common spelling variations for a disorder (eg ‘type 1 diabetes’ versus ‘type I diabetes’ or ‘diabetes type 1’). Practices could provide a list of common usage and standard terms to all practitioners.

Using a recognised medical vocabulary and standardised terms in health records will mean:

key details of a consultation can be recorded in a standardised way
patient records can be understood more easily by health professionals who have not seen the patient before
data can be easily and accurately retrieved for auditing, quality improvement, reviewing particular patient populations (eg eligibility for flu vaccinations)
analysis of practice data is more reliable and accurate.

Our practice started participating in NPS’s MedicineInsight program, and because part of the feedback is dependent on the quality of the data, we really saw the importance of using correct data entry fields.
– Member, RACGP Expert Committee – eHealth and Practice Systems

Relevant indicator

QI1.3A Our practice team uses a nationally recognised medical vocabulary for coding.

You could:

use patient management software to code patient health information.

Tips for consistent records

Educate practice staff about the importance of entering information in a standardised way, and provide training in how to take full advantage of the clinical software’s structured data entry.
Maintain an agreed-upon list of standard terms, acronyms and abbreviations that are generally used by healthcare professionals in the practice and by the broader health community. Ensure that everyone in the practice can easily access it.
Clinicians may set up shortcut keys or autocorrect to spell out common abbreviations in full.
Use clinical tools to help collect consistent information from particular populations – for example, a template of questions for baby checks that is linked to fields in the record.

Easily read and understood

Health records should be legible and written in a way that is meaningful to other users.

Information in health records should be legible and presented in a way that is meaningful to other people who will access the record – including patients themselves. Documenting health records in a meaningful way can facilitate continuity of care and improve patient outcomes.

The legibility and readability of health records will be influenced by:

Box 3.

Language use in high-quality health records The kind of language used in free-text information can affect how well that information is understood. Language in high-quality health records is clear, unambiguous and meaningful to others.

Remembering that patients can access their own records, and should be able to understand them, GPs should avoid using jargon, shorthand and abbreviations. It is also important that language is respectful.

Tips for legible records

Avoid idiosyncratic abbreviations, shorthand and jargon (refer to ‘Consistent’ above).
Clinicians who aren’t strong typists may consider using voice-recognition software to record computer notes.
Conduct regular ‘peer reviews’ of health records to see whether they can be easily understood by other GPs.

Accessible

Health information should be recorded in ways that make it readily retrievable.

A practice’s health record system should make it easy to retrieve information for a range of purposes. This includes having clear information and procedures for patients to access their records.

A fully electronic system is preferable, as information is most easily retrievable from these systems.

Relevant indicators

C6.2A Our practice has a system to manage our patient health information.

You must:

have a system to manage patient health information
have all patient health information available and accessible when needed.

C6.2B If our practice is using a hybrid patient health record system, a note of each consultation/interaction is made in each system, and that record includes where the clinical notes are recorded.

You must:

keep a record of consultations in both the paper and electronic health record
have all patient health information available and accessible when needed.

C6.3B Our patients are informed of how they can gain access to their health information we hold.

You must

maintain a privacy policy.

We have the case discussions in our practice with the registrars seated around a computer. Another doctor looks at the record and we discuss as a team if the record is clear to the other doctor. My typos are legendary in this gentle and supportive exposé!
– Member, RACGP Expert Committee – eHealth and Practice Systems

Up to date

Up to date Information should be recorded in patient health records in a timely manner.

Ensuring information is recorded in a patient’s record as soon as possible after it is collected helps with accuracy and completeness of records. Information collected during a consultation should be recorded at the time, or as soon as possible afterwards. Information received from other sources should be entered into a patient’s record within a reasonable time frame.

Tips for ensuring records are up to date

Set aside time for GPs to maintain patient records, including time to review information that needs be entered from external sources. For example, incorporate gaps into daily appointment schedules, or make appointment times long enough for completing notes.
Set up practice systems, such as software prompts, to remind the practice team to regularly review smoking and drinking status, rather than just ‘setting and forgetting’.

Case study

At a major metropolitan after-hours deputising service, GPs beginning their shift would often be assigned 10 or more patients to triage, prioritise and then visit. The service found that doctors were having trouble completing patient records at the end of each shift, as many hours might have passed since seeing a patient before a doctor sat down to complete their consultation notes.

Because of concerns about the completeness of information recorded this way, the service changed its procedures so that each doctor received no more than three patients at a time to assess and visit. They were then given time to complete their consultation notes, before being assigned additional patients, until the end of the shift.

By making a fairly small systematic change, along with introducing a monthly internal audit of patient records, the service made a significant improvement in the quality of its patient health records.

Case study

An RACGP-accredited general practice in Queensland has established an ‘accreditation taskforce’, which includes a representative from each ‘team’ within the practice (GPs, administrative staff, clinical nurses, specialist nurses and reception staff).

One of the ongoing tasks for the GPs on the committee is to audit doctors’ notes and mentor doctors whose notes are not of the appropriate standard. This process to ensure the quality of health records has led to:

one GP completing a touch-typing course to improve their keyboard skills
setting up practice-wide templates and autotext for common terms in the clinical information system to help GPs produce clinical records of an appropriate quality.

This practice also has a ‘quality improvement team’ to drive quality improvement within the practice, including improvements in health records. One of the achievements of this team has been the consistent coding of consultations across the practice.

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