Standards for general practices

Core module

Criterion C6.2 – Patient health record systems

        1. Criterion C6.2 – Patient health record systems

Indicator


C6.2 A Our practice has a system to manage our patient health information.

C6.2 B If our practice is using a hybrid patient health record system, a note of each consultation/interaction is made in each system, and that record includes where the
clinical notes are recorded.

Why this is important

Patient health record systems operating in practices are generally electronic, paper-based or a hybrid of both electronic and paper-based systems.

Your practice has an active hybrid patient health record system if one or more of your practitioners enter patient information into a paper-based system and one or more uses electronic files.

A fully electronic patient health record system is preferable to a paper-based or hybrid system because clinical notes in an electronic system:

  • are more legible
  • are more accessible
  • reduce duplication
  • are more easily protected and backed up, which means your practice is less likely to lose or misplace information as a result of incorrect filing, natural disaster, fire or theft.

In addition, electronic systems can support clinical decision making (eg alerts can be set for patient allergies, and the patient’s detailed medical history, including past and current medications and dosages, can be accessed more easily).

Using an active hybrid patient health record system to record patient health information is discouraged, as it can result in some information being recorded on one system (eg a medicines list on a computer) and some information being recorded on another system (eg past medical history on handwritten notes), or some information not being recorded at all.

Meeting this Criterion

Your practice must have a patient health record system that suits the needs of your practice, whether it is an electronic, paper-based or hybrid system.

Using a hybrid patient health record system

If you use a hybrid patient health record system:

  • all practitioners in your practice, including locums, must know that the patient health record system is a hybrid
  • all practitioners, including locums, who see a patient must know to look at both systems in order to access all relevant information
  • information in both systems must be readily available at all times
  • information does not need to be duplicated in both systems, but there must be a clearly visible note in both systems stating that the practice uses a hybrid patient health record system and where information is recorded
  • you must be working towards recording at least allergies and medications electronically.

Meeting each Indicator

C6.2 A Our practice has a system to manage our patient health information.

You must:

  • have a system to manage patient health information
  • have all patient health information available and accessible when needed.

You could:

  • use clinical software to manage patient health information
  • conduct audits to identify gaps in patient information
  • provide relevant education to the practice team when the clinical software is updated.

C6.2 B If our practice is using a hybrid patient health record system, a note of each consultation/ interaction is made in each system, and that record includes where the clinical notes are recorded.

You must:

  • keep a record of consultations in both the paper and electronic health record if using a hybrid system
  • have all patient health information available and accessible when needed.

You could:

  • transition to a completely computerised patient health information system.

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