Introduction
Quality health records are essential for delivering safe and effective care in general practice. They help general practitioners (GPs) make informed clinical decisions, support continuity of care, and serve as the foundation for clinical audits and quality improvement.
Health data from general practice records is often shared with other healthcare providers across primary, secondary, and tertiary settings. It can also be used for research, education, policy development, and legal purposes. All of these rely on records being accurate, complete, and well-maintained. Furthermore, The Ahpra Code of Conduct requires registered health practitioners to maintain clear and accurate health records as part of professional responsibility.
Despite its importance record keeping is not always a high priority for busy GPs. To prioritise effective record keeping, it must become part of routine practice and the importance of a practice culture that promotes high-quality health records cannot be understated. This may take time to develop, and it requires strong leadership, ongoing education and workplace policies and systems should help facilitate this culture and quality health records.
About this resource
This guide supports GPs and their teams to recognise what makes a quality health record and provides practical ways to improve and maintain record quality.
Disclaimer
This document does not constitute legal advice. The RACGP takes no responsibility for any loss of any description by a practice or person as a result of relying on this document.