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Education toolkits for general practice

High-quality health records

Attributes of high-quality health records

Last revised: 17 Jun 2020

High-quality health records have six features. They are:

  • Accurate – correctly reflects the patients details, information captured in consultation, and information collected from other sources.
  • Complete – contains sufficient information, keeping in mind the ‘expect to share’ principle
  • Consistent – uses a recognised medical vocabulary, standardised terms and abbreviations
  • Legible – easily read and understood; written in a way that is meaningful to other users
  • Accessible – data is recorded in ways that make it readily retrievable
  • Up-to-date – updated in a timely manner.
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