Criterion C7.1 – Content of patient health records

Why this is important

Complete patient health records improve patient safety and wellbeing as they support clinical decision making. For example, a complete patient health record assists your clinical team to easily access information on a patient’s allergies or the patient’s medical history.

Consultation notes and patient health records are also a way of managing risks. Medical defence organisations have identified that failure to follow up matters that patients have previously raised poses a considerable risk to practices and practitioners.

Meeting this Criterion

Content of patient health records

Patient health records must be updated as soon as practicable during or after consultations and home and other visits. The record must identify the person in the clinical team making the entry.

All patient health records, including scans of external reports, must be legible so that another practitioner could take over the care of the patient. Consultation notes must contain the following information:

• Date of consultation
• Who conducted the consultation (eg by initials in the notes, or by audit trail in an electronic record)
• Method of communication (eg face to face, email, telephone or other electronic means)
• Patient’s reason for consultation
• Relevant clinical findings including history, examinations and investigations
• Allergies
• Diagnosis (if appropriate)
• Recommended 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 (eg a medical student)
• Record of patient emails (if applicable)

When available, use consistent coding of diagnoses. Choose the most appropriate diagnosis from a recognised clinical terminology (one of these is supplied with every electronic clinical record package) in the consultation notes so that continuous improvement of clinical care and patient outcomes can be achieved.

Other information may be included in the patient health record, such as:

• any referrals to other healthcare providers or health services
• medicines the patient takes that were not prescribed or advised by the practice
• complementary and over-the-counter medicines (because many people now take complementary and over-the-counter medicines that may react adversely with conventional medicines, you could document the patient’s use of these as you would other medicines, whether prescribed by a member of the clinical team or reported by the patient)
• any relevant preventive care information collected, such as currency of immunisations, blood pressure, waist measurement, height and weight (body mass index)
• immunisations
• an advance care plan
• the presence of a third party brought in by the patient (eg carer)
• any special advice or other instructions given to the patient.

System to store patient health information

You need to have an effective system to store patients’ health information in a dedicated patient health record. In addition to containing clinical information, the patient health record may also contain other relevant information, such as details of personal injury insurance claims.

Patient health records in clinical software

Consider updating medical software when practicable. This will mean that older files will remain compatible with later versions of the software, and that you will be able to run the software on modern hardware and operating systems.

You might consider retaining older hardware and operating systems so that you can store and retrieve older records.

Collecting information from patients

Patient privacy is critical when collecting information that forms part of a patient health record, including all demographic and health information. You can collect information from a new patient using a generic form, on paper or electronically, or by privately interviewing patients before the first consultation. You must ensure patients can provide information privately. If clarification of any patient details is needed, ensure you do so in a private space, preferably away from the practice’s waiting area. Consider the sensitivity of details being collected or clarified, and determine whether a clinician or practice nurse is best suited to ask the patient for that information (eg in a private consultation room). For more information, refer to Criterion C6.3 – ‘Confidentiality and privacy of health and other information’.

You must have a system that ensures that patient information (including the contact details of their emergency contact) is updated regularly so that it remains accurate.

Collecting information about sex, gender, variations of sex characteristics and sexual orientation

Data-collection methods often do not distinguish between an individual’s identity and the labels other people might use about them. For example, people who are classified as ‘transgender’ by others might self-identify as women or men. Someone who was assigned ‘male’ at birth and whose documents list sex as ‘male’ might select ‘woman’ as her gender, ‘female’ as her sex on a form, ‘her/she’ as her pronouns and not identify as ‘transgender’.

Missing or misrepresented information in a patient’s health record can have substantial implications for clinical care delivery. For example, a male patient whose assigned sex at birth is ‘female’ still requires screening for female disease risk factors. If a patient’s assigned sex at birth and gender are conflated and inaccurately recorded, appropriate treatments might not be offered. Your practice needs to explain the reason for collecting this information to patients, so they know data are being confidentially collected for their own health outcomes, not for discriminatory or judgemental reasons.

Likewise, information about gender can be interrelated to various aspects of the patient’s health (eg expression and experience of mental health), so it is important that this information is collected independently of assigned sex at birth.

There is no singular experience or identity for people born with variations of sex characteristics (intersex). When your practice seeks to obtain information about variations of sex characteristics, you need to ask patients a separate question from those asking about assigned sex at birth and gender. When asking about a patient’s sex, do not include ‘intersex’ or ‘born with a variation of sex characteristics’ alongside the options ‘male’ and ‘female’. Doing so might be perceived as offensive or inaccurate when the patient identifies as male or female. A patient born with a variation of sex characteristics might identify as both intersex and male or female, so conflating sex and variations of sex characteristics in a single question could be perceived as offensive or inaccurate.

For the best health outcomes, ask for and record details about a patient’s sex, gender, variations of sex characteristics and sexual orientation separately. Your practice could do the following to improve the accuracy of responses when collecting this information from patients:

• Clearly explain why questions are being asked and how answers will be used.
• Use forms that allow patients an option from multiple fields (eg see formats for preferred question and answer options below).
• Ask patients what pronouns they use, then document and use this information (eg in referral letters).
• Ask questions that distinguish between identity (ie male/female) and descriptors of behaviour, attraction and experience (ie ask who your patient’s sexual partners are).

For more information, refer to the RACGP’s fact sheet, Collecting and recording information about patient sex, gender, variations of sex characteristics and sexual orientation.

Collecting information over time

Patient information is gathered over more than one consultation. It is important that clinically significant, separate events in a patient’s life and the care provided are recorded and managed so that the information is readily accessible.

One way of doing this is to regularly update each patient’s health summary so that all relevant information is easy to find in one central location.

Clinically significant information may include the patient’s health needs and goals, preventive health activities, medical conditions and their preferences and cultural values. Having this information improves the practitioner’s ability to provide care that is tailored to the patient’s needs and circumstances.

Identifying patients of Aboriginal or Torres Strait Island origin, or another cultural background

The RACGP encourages you to identify and record the Aboriginal or Torres Strait Islander status and cultural background of all patients, as this information can be an important indicator of clinical risk factors and therefore help practitioners to provide relevant care.

Before asking a patient any questions about their cultural background, explain that knowing such information helps the practice provide appropriate healthcare.

Routinely ask all patients the following question regardless of the patient’s appearance, country of birth, or whether the practice team know of the patient or their family background.

‘Are you of Aboriginal or Torres Strait Islander origin?’

All patients have the right to respond to this question as they see fit. If a patient indicates that they do not wish to answer the question, record ‘Not stated/inadequately described’. The patient’s response must be received without question or comment, and the response must be recorded without any amendments or annotations.³⁰ However, if the patient does not answer this question when it is on a form, you need to follow up immediately in case they missed it by mistake, rather than assume that the patient has refused to answer.

Collecting information about a patient’s cultural heritage before a consultation (eg by using a new patient form) will help you to provide the most appropriate care.

Where patients were born, where they grew up, or where their parents are from may indicate that they are at higher risk of developing certain health conditions. Similarly, this and other information, such as the language spoken at home, can help to identify patients who require specific care or targeted interventions. It is good practice to record this information in the patient health record if it is relevant to their patient care.

Retaining health records of active and inactive patients

Your practice must keep and securely store and dispose of health records of active and inactive patients in accordance with legal obligations imposed by the Privacy Act 1988 and the APPs.

An inactive patient is generally defined as a patient who has attended the practice twice or less in the past two years.

You must retain health records of inactive patients in accordance with relevant national, state or territory laws. You may want to consult your medical defence organisation when creating the practice’s policy about the retention of records of inactive patients.

Lifestyle risk factors

Lifestyle risk factors such as smoking, nutrition, alcohol and physical activity are associated with many diseases. Record these risk factors in the patient health record and review management plans at defined intervals.

Routinely measure and record each patient’s height, weight and blood pressure at defined intervals. This will help you to identify significant or unexplained weight loss or gain that may indicate a disease, and/or to assess a child’s growth and development. The practitioner must know which health checks need to occur at what intervals, in accordance with best practice.³¹

Meeting each Indicator

C7.1 A Our practice has an individual patient health record for each patient, which contains all health information held by our practice about that patient.

You must:

You could:

• maintain a policy addressing the management of patient health information
• ensure handwritten records are legible
• ensure new patient forms ask for all required information
• cover policies and processes relating to patient health records during staff inductions.

C7.1 B Our active patient health records contain, for each active patient, their identification details, contact details, demographic, next of kin, and emergency contact information.

You must:

You could:

• maintain a policy addressing the management of patient health information
• use a new patient form that asks for all required information.

C7.1 C  Our patient health records include records of consultations and clinical related communications.

You must:

You could:

• maintain a policy addressing the management of patient health information
• check documents that are scanned into electronic health records are clear and can be easily read, and make appropriate notes if anything is unclear or illegible.

C7.1 D Our patient health records show that matters raised in previous consultations are followed up.

You must:

You could:

• maintain a policy addressing the management of patient health information
• use flags in the consultation notes to mark issues that need to be followed up.

C7.1 E Our practice routinely records the Aboriginal and/or Torres Strait Islander status of our patients in their patient health record.

You must:

You could:

• maintain a policy addressing the management of patient health information.

C7.1 F Our practice routinely records the cultural backgrounds of our patients in their patient health record.

You could:

• maintain a policy addressing the management of patient health information
• ask patients about their cultural background during a consultation, and record this information in your clinical software (in a specific field or in general notes)
• ask patients about their cultural background in your new patient form, and enter this information into your clinical software system (in a specific field or in general notes).

C7.1 G Our patient health records contain, for each active patient, lifestyle risk factors​.

You must:

You could:

• maintain a policy addressing management of patient health information.