Understanding and creating quality health records

Quality health records in general practice

Understanding and creating quality health records

Quality health records reflect a patient’s clinical care and are:

  • Easily read and understood,
  • Current,
  • Complete,
  • Accurate, and
  • Consistent.

More information on each of these attributes can be found below.


Information in a health record should be legible and presented in a way that is meaningful to others who will access the record, to facilitate continuity of care, and improve patient outcomes.

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

  • keyboard and typing skills 
  • use of AI scribes
  • familiarity with software and shortcuts 
  • the quality of scanned documents 
  • how forms are designed or laid out 
  • use of suitable typefaces 
  • language use.  

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

Take action – Tips for maintaining easily read and understood records

  • Avoid personal abbreviations, shorthand and jargon.
  • Conduct regular peer reviews of health records to see whether they can be easily understood by other GPs. Peer reviews undertaken to improve quality care and training are permitted under the Australian Privacy Principles.
  • Promote an ‘expect to share’ mindset among the GPs and the practice team: that is, encourage colleagues to write their notes as if they will be read by others.
  • Clinicians who aren’t strong typists may consider using AI scribes to record consultation notes.


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 after the consultation. Information received from other sources should be entered into a patient’s record as soon as possible.

Take action – Tips for maintaining current records

  • Ensure there is time in the work day to maintain patient records, including time to review information that has been entered from external sources.
  • Set up practice systems, such as software prompts, and reminders to regularly review lifestyle factors such as smoking status, rather than just ‘setting and forgetting’.


GPs should consider the different purposes of health information outlined in the Why quality matters section of this resource when recording information during a consultation. 

At a minimum, the RACGP’s Standards for general practices (5th edition) require health records to contain: 

  • date of consultation 
  • who conducted the consultation (e.g. by initials in the notes, or by audit trail in an electronic record) 
  • method of communication (e.g. face to face, email, telephone, or other electronic means) 
  • consent to the use of an AI scribe (if relevant)
  • patient’s reason(s) for consultation 
  • relevant clinical findings including history, examinations, and investigations 
  • diagnosis (if appropriate) 
  • management plan and, where appropriate, expected process of review 
  • any medicines prescribed for the patient (including the name, strength, directions for use, dose, frequency, number of repeats and date on which the patient started/ceased/changed the medication) 
  • patient consent for the presence of a third party brought in by the practice (e.g. a medical student) 
  • reasons why care recommended by guidelines, such as vaccinations, was not offered or provided

Take action - Tips for maintaining complete records

  • Use patient registration forms (paper or electronic self complete) so required information is routinely captured.
  • Develop policies and procedures involved in managing health information 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 you would find helpful to manage unfamiliar patients.


Accurate health information is critical to patient care. However, clinical information can be variable, uncertain, and at times incomplete due to the variability of language and clinical terms used by GPs.

Practices and GPs need to ensure records correctly reflect:

  • information that could feasibly identify a patient, including demographic details, individual healthcare identifier, Medicare number/DVA number
  • information captured during consultations
  • information collected from other sources.

Take action – Tips for maintaining accurate records 

  • Regularly check 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 change patient clinical records.
  • Confirm the identity of each patient and ensure this is matched to the correct health record before the consultation begins.
  • Record and review ‘near misses’ regarding incorrect or inaccurate incorporation of patient information into records as part of a clinical risk management process.


Using a recognised medical vocabulary and standardised terms ensures consistency when recording diagnoses, observations, and procedures. This standardisation makes health records easily read and understood by all healthcare professionals involved in a patient’s care.

Most clinical information systems incorporate nationally recognised vocabularies, coding, or classification systems. These systems support structured data entry (such as drop-down menus, picklists, or automated natural language processing), allowing clinicians to record diagnoses, prescriptions, pathology, and diagnostic results. The software automatically codes and classifies this data, ensuring patient records contain standardised information.

While free-text entries provide essential narrative context, they are prone to ambiguity and challenging to search. Clinicians should use free-text fields to complement coded data and choose terms carefully to ensure clarity for all readers, including patients. Practices can standardise free-text terminology and address spelling variations by providing clinicians with agreed-upon terms.

Adopting recognised vocabularies and standardised terms enables:

  • consistent recording of key consultation details
  • clear understanding of patient records by all healthcare providers
  • accurate retrieval of data for audits, quality improvement, and population health management (eg, flu vaccine eligibility)
  • reliable practice data analysis
  • enhanced clinical decision support through coded data, improving safety via alerts for medication contraindications and management recommendations
  • seamless information exchange with external systems (eg, that of other specialists and hospitals) using the same vocabularies.

Take action - Tips for maintaining consistent records

  • GPs and the practice team undertake education activities to understand the the importance of entering information in a standardised way.
  • Provide training on 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 for use by the practice team.
  • 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 health checks that is linked to fields in the record.
  • Use software which has recognised vocabularies embedded into its functions.
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