Improving health record quality in general practice

Why quality matters

Last revised: 05 Dec 2023

General practice patient health records have a number of primary and secondary purposes (Box 1), but their purpose is to support safe, effective and appropriate care for individual patients and practice populations. The quality of health records kept by general practices – including how complete they are, their accuracy and legibility – is therefore critical. This is even more the case as patient health records are increasingly shared with other health practitioners and services (refer to ‘Expect to share’, below).

High-quality health records facilitate:

  • safe clinical decision making
  • effective communication between health professionals
  • trusting partnerships with patients
  • coordination and continuity of care.

In addition to facilitating care, high-quality health records also provide evidence of care. Doctors who face medico-legal claims will have a better case if their records are complete and demonstrate comprehensive care of their patient.

The way general practice health records are created and used is changing (Figure 1). Many practices are multidisciplinary, patients may be on shared care plans, and from late 2018, all Australians known to Medicare and the Department of Veterans’ Affairs will automatically have a My Health Record created for them, unless they choose to opt out.

GPs are therefore no longer producing health records only for the benefit of themselves or their immediate colleagues, and the assumption of all GPs in a practice should be that at some point, the information they enter into a patient’s health record will be shared. A patient’s health record might be used by a range of health professionals and services to provide healthcare; it might be accessed by patients themselves or required by third parties (eg for medico-legal purposes).

To be fit for sharing, patient health records therefore need to be of the highest possible quality.

Box 1. Primary and secondary purposes of health records

Health records may serve multiple primary and secondary purposes.

Primary purposes include:

  • helping GPs make decisions about patient care, by providing a structure for thoughts and a record of previous consultations
  • recording consultations provided by a range of health professionals to facilitate safe and effective care for patients and practice populations
  • providing a source of information to be shared appropriately with other health professionals to facilitate safe and effective care
  • providing a source of information to be shared with patients to facilitate a partnership in healthcare based on trust and respect.

Secondary purposes include:

  • a tool for education, training and professional development
  • a source of health information for clinical audits and quality improvement initiatives
  • a source of health information to support the planning, commissioning, coordination and governance of primary healthcare services a potential source of data for approved research
  • evidence for medico-legal purposes.

How use of general practice health records is changing

Figure 1.

How use of general practice health records is changing

Currently, Australian general practice records are transitioning from locally held electronic health records, where some information is shared within a practice, to shared electronic health records, where local clinical information might be used by a range of healthcare providers.

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