Education toolkits for general practice

High-quality health records

Practice-level strategies to improve data quality

Last revised: 17 Jun 2020

There are several ways to improve data quality in health records at the practice level.
  1. Developing policies and procedures. Good practice begins with well-maintained policies and procedures. All practices should have documented policies and/or checklists for:
    1. Using the health record system
    2. Managing risk in the health record system (eg ensuring information is entered into correct records)
    3. System security
    4. Handling health record information (eg for entering information from outside sources and exporting information).
  2. Providing education and training. This should begin during the induction of new staff, both clinical and administrative. Staff should be provided with information about where they can go to access support about the maintenance of health records.
  3. Measuring progress. In order to see improvement, you need to be able to measure progress against your goal. General practices can use data analysis tools such as PEN CAT4 or POLAR to do this. Depending on the specific goal you are working towards, you can build a register of patients with a particular condition (eg diabetes) or identify at-risk patients (eg patients with a chronic condition who do not have a GP management plan in place).
  4. Creating an action plan. As per the RACGP Standards, it is necessary to develop business goals aimed at improving services, and then evaluate progress towards these goals.
  5. Create a culture of good data quality. Changing from current practice to the consistent use of structured data requires a whole-of-practice effort. It is necessary to have the whole practice team on board. The key to change will be to create a culture of continuous improvement, where all team members are encouraged to work towards the goal. Some things that your practice could do include:
    1. Creating a staff noticeboard for improvement activities, with reminders and graphs of progress etc
    2. Considering KPIs for improving particular types of essential clinical data
    3. Producing regular reports to show individual and practice progress towards the goal
    4. Ensure all staff have sufficient time to update health records. For example, if required, provide brief gaps in daily appointment schedules for GPs to complete consultation notes.
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