Standards for general practices

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Standards for general practices

Last revised: 24 Feb 2023

Definitions of terms used in this document.

Term	Definition
Aboriginal or Torres Strait Islander status	A way of recording and identifying a patient’s response when the practice asks them, ‘Are you of Aboriginal and/or Torres Strait Islander origin?’ The standard response options should be provided either verbally or in written form: No Yes, Aboriginal Yes, Torres Strait Islander For people of both Aboriginal and Torres Strait Islander origin, both ‘Yes’ boxes should be marked when in written form
Aboriginal and Torres Strait Islander health worker/practitioner	A member of the Aboriginal and Torres Strait Islander health workforce. Roles include, but are not limited to: providing clinical functions liaison and cultural brokerage health promotion environmental health community care administration management and control policy development program planning An Aboriginal and Torres Strait Islander health worker/practitioner is often an Aboriginal and Torres Strait Islander person’s first point of contact with the health workforce, particularly in remote parts of the country
Access	The ability of patients to obtain services from the practice
Accreditation	A formal process to assess a practice’s delivery of healthcare against the RACGP’s Standards for general practices
Action plan	A document that lists the steps to be taken to achieve a specific goal
Active patient	A patient who has attended the practice/service three or more times in the past two years
Active patient health record	The health record of an active patient
Administrative staff members	Members of the practice team who provide clerical or administrative services and who do not perform any clinical tasks with patients
Adverse event	An adverse event, or incident, is any event or circumstance arising during care that could have or did lead to unexpected actual harm, loss or damage. Incidents include near misses, sentinel events and unsafe acts.
Adverse medicines event	An adverse event caused by a medicine; this includes harm that results from the medicine itself (an adverse drug reaction) and potential or actual patient harm that comes from errors or system failures associated with the preparation, prescribing, dispensing, distribution or administration of medicines (medication incident)
After-hours service	A service that provides care outside the normal opening hours of a general practice, whether or not that service deputises for other general practices, and whether or not the care is provided physically in or outside of the clinic
Allied health professional	A health professional who collaborates with doctors and nurses to provide optimal healthcare for patients (eg physiotherapist, dietitian, podiatrist)
Appointment system	The system that a practice uses to assign consultations to patients and practitioners
Backup	A copy of all the files stored on a computer’s or server’s hard drive made onto another device such as a portable drive or an offsite server
Buddy system	A system that enables a ‘buddy’ to follow up results and correspondence or continue the care of patients on behalf of an absent colleague
Business continuity plan	A plan that specifies how a practice will continue providing services if it is affected by disasters of various levels of severity
Care outside of normal opening hours	Clinical care that is provided to the practice’s patients when the practice is normally closed
Carer	Person who provides care and support to a family member or friend who is frail, or has disability, mental illness, chronic condition or terminal illness
Chaperone	An impartial observer to a consultation between a practitioner and a patient
Clinical governance	A framework through which clinicians and health service managers are jointly accountable for patient safety and quality care
Clinical handover	The transfer of professional responsibility and accountability for some or all aspects of a patient’s care, from one professional person or group to another
Clinical indicator	A measure, process, or outcome used to assess a particular clinical situation against the RACGP’s Standards for general practices, and determine whether the care delivered was appropriate
Clinical risk management system	A system to manage the risk of errors and adverse events in the provision of healthcare
Clinical significance	A way of referring to an assessment of: the probability that a patient will be harmed if they do not receive further medical advice, treatment or other diagnostics the likely seriousness of the harm
Clinical team	All members of the practice team who have health qualifications that qualify them to perform clinical functions
Clinical team member	An individual member of the practice team who has health qualifications that qualify them to perform clinical functions
Code of conduct	A set of principles that characterise good practice and explicitly state the standards of ethical and professional conduct that professional peers and the community expect of members of the practice team
Cold chain management	The system of transporting and storing vaccines from the place of manufacture to the point of administration in order to keep the vaccines within the temperature range of 2–8°C
Communicable disease	An infectious disease that is transmissible from one person to another, or from an animal to a person, by: direct contact with an infected person direct contact with an infected person’s discharges indirect means
Complaint	Any verbal or written expression of dissatisfaction or concern with an aspect of the general practice. A complaint may be made using, for example, a complaints process, consumer surveys or focus groups
Comprehensive care/ Comprehensiveness	Comprehensive care is the coordinated delivery of the total health care required or requested by a patient. The scope of clinical practice is challenging, spanning prevention, health promotion, early intervention for those at risk, and the management of acute, chronic and complex conditions within the practice population whether in the home, practice, health service, outreach clinic, hospital or community. Comprehensiveness ensures services are not limited by body system, disease process or service site. This use of ‘comprehensiveness’ in this definition is not intended to change the requirements for general practice as a speciality or for training purposes. This definition is to be used for practice accreditation. For training and achieving Fellowship the definition of Comprehensive Australian general practice must be used.
Confidentiality	The act of keeping information secure and/or private, so that it is only ever disclosed to an authorised person
Consequence	The effect that an event had, has, or would have, on one or more of the practice’s objectives
Consultation note	A note in a patient’s health record, made during or after a consultation, that contains relevant information about the consultation
Continuing Professional Development (CPD)	Educational activities endorsed by the RACGP that lead to improved quality of clinical care
Continuous care / Continuity of care	When a patient experiences a series of discrete healthcare events and/or services that are coherent, connected and consistent with their medical needs and personal circumstances
Cooperative	A group of general practices that have an arrangement to work together to provide care to patients outside the normal opening hours of their practices
Cultural background	Details of a patient’s ethnic or cultural heritage that the practice has collected and recorded
Cultural safety	The condition created when people respect, and are mindful of, a person’s culture and beliefs, and do not discriminate against that person because of their culture or beliefs
Demographic	A particular sector of a population
Disability	Term for any or all of the following components: Impairments resulting in problems in body function or structure Activity limitations resulting in difficulties in executing activities Participation restrictions resulting in problems in involvement in life situations
Discrimination	Different treatment or consideration of a patient based on particular characteristics (such as gender, age, ethnicity or religion). Positive discrimination enhances the care given to the patient, and negative discrimination potentially reduces, or does reduce, the quality of that patient’s care
Duty of care	The legal obligation to safeguard others from harm while they are in your care, using your services, or otherwise exposed to your activities
Electronic communication	The transfer of information (including, but not limited to, patient health information) within or outside the practice using email, internet communications, text message or facsimiles
Emergency contact	The person whom a patient has nominated to be contacted in an emergency
Encryption	The process of converting plain text characters into meaningless data to protect the contents of the data and guarantee its authenticity
Enrolled nurse	A nurse who works under the direction and supervision of a registered nurse as stipulated by the relevant nurse registering authority, but remains responsible for their own actions and accountable for the delegated nursing care they provide
Environmental cleaning	The process of removing all visible dust, soils and other material from a surface
Ergonomic assessment	The process of evaluating the extent to which a workstation and workspace is designed to minimise the risk of injury and to maximise productivity. This is also referred to as a workstation assessment
Ethical dilemma	The need to choose between two courses of action, both of which will result in an ethical principle being compromised
Ethics (or code of behaviour)	The principles adopted by an organisation to ensure that all its decisions and actions conform to normal and professional principles of conduct
Firewall	Security software that prevents unauthorised (and usually external) access to information stored on a private network, and controls the flow of data according to specific rules defined by the practice
Follow up	Activities that are the logical and responsible steps to take after taking earlier related actions, including: making a phone call to find out the status of tests and results that are expected but not yet been received contacting a patient to discuss a report, test or results
Gender	Gender is a social and cultural concept. It is about social and cultural differences in identity, expression and experience as a man, woman or non-binary person. ‘Non-binary’ is an umbrella term describing gender identities that are not exclusively male or female
General practice	The provision of patient-centred, continuing, comprehensive, coordinated primary care to individuals, families and communities
General practitioner (GP)	A registered medical practitioner who: is qualified and competent to provide general practice anywhere in Australia has the skills and experience to provide patient-centred, continuing, comprehensive, coordinated primary care to individuals, families and communities maintains professional competence in general practice
Hardware	The physical components of a computer, including monitors, hard drives and central processing units
Harm	A damaging effect on a person, such as disease, injury, suffering, disability or death. Harm may be physical, social or psychological
Health information	A subset of a patient’s personal information that is collected in connection with the provision of a health service. It includes information or opinions about the health or disability of an individual, and a patient’s wishes about future healthcare and health services
Health outcome	The health status of an individual, group of people or specific population that is wholly or partially attributable to an action, agent, or circumstance performed, provided or controlled by a general practice or other health professionals (eg nurses and specialists)
Health promotion	The process of enabling people to improve and increase their control over their health. As well as influencing an individual’s behaviour, it also encompasses a wide range of social and environmental interventions
Health summary	Documentation usually included in a patient’s health record that provides an overview of all components of the patient’s healthcare (eg current medications, relevant past health history, relevant family history, allergies and adverse drug reactions)
High-risk results	Clinical test results that are seriously abnormal and life-threatening and need to be communicated in an appropriately timely manner
Home visit	A general practice consultation conducted in the patient’s (or someone else’s) home
Human research ethics committee (HREC)	A committee constituted according to National Health and Medical Research Council requirements that reviews applications from people or organisations undertaking research projects involving human subjects
Human resources	People who work in an organisation OR An area of business management that addresses the recruitment, training and management of the people who work in an organisation
Hybrid patient health record system	A combination of paper-based or electronic systems used by one or more practitioners to enter patient information
Incident	An event or situation that resulted, or could have resulted, in: unintended and/or unnecessary harm to a person a complaint, loss, damage or claim for compensation
Indemnity	Provides security or protection against a loss or other financial burden. Medical indemnity insurance is a compulsory condition of registration for all medical practitioners in Australia.
Individual healthcare identifier	A patient’s unique 16-digit number allocated by the Department of Human Services (each eligible Australian patient who seeks healthcare is allocated one)
Induction program	Training provided to new team members to introduce them to the practice and its systems, processes and structures
Infection	The invasion and reproduction of pathogenic (disease-causing) organisms inside the body that can cause tissue injury and can lead to disease
Infection control measures	Actions to prevent the spread of pathogens between people in a healthcare setting
Information management	The policies, processes and systems that govern the creation, use and storage of information
Information security	The protection of the confidentiality, integrity and availability of information
Interpreter service	A service that provides trained language interpretation or translation, either face to face or by telephone
Informed consent	The written or verbal consent that a patient gives to the proposed investigation, proposed treatment, or invitation to participate in research, when they understand the relevant purpose, importance, benefits and risks. For consent to be valid, a number of criteria need to be satisfied, including the: patient having received and understood sufficient and appropriate information, and being aware of the material risks patient having the mental and legal competence to give consent
Informed refusal	A patient’s refusal of proposed or recommended medical treatment when they understand all relevant information, including the implications of refusing the treatment
Innate variations of sex characteristics	‘Variations of sex characteristics’ refers to people with innate genetic, hormonal or physical sex characteristics that do not conform to medical norms for female or male bodies. It refers to a wide spectrum of variations to genitals, hormones, chromosomes and/or reproductive organs. Other umbrella terms used to describe being born with variations of sex characteristics are ‘intersex’ or ‘differences/disorders of sex development’
Intersex	People who are born with genetic, hormonal or physical sex characteristics that are not typically male or female
Issue	A relevant event that was not planned (eg a problem, query, concern or risk) and requires action
LGBTIQA+	Initialism for lesbian, gay, bisexual, transgender, intersex, queer and asexual, or other gender and sexual diversities. Other common variations include LGBTI and LGBTIQ
Lifestyle risk factors	Habits or behaviours that people choose to engage in that, if changed, can directly affect some medical risk factors by reducing the likelihood of developing disease
Medical consumable	A medical product used for a therapeutic purpose that is not pharmaceutical and is not re-usable (eg a syringe)
Medical deputising service	A service that arranges for, or facilitates, the provision of medical services to a patient by a medical practitioner (deputising doctor) during the absence of, and at the request of, the patient’s GP (principal doctor)
Medicine	A drug or other preparation for the treatment or prevention of disease
Mission	The overall function of an organisation
Natural immunity	Immunity to a particular infection that is not the result of vaccination or previous infection but is inherent in the genetic make-up of an individual, family, etc
Near miss	An incident that did not cause harm, but could have
Network	A group of connected computers and peripheral devices used to store and share information electronically
Next of kin	A person’s closest living relative or relatives, as identified by that person
Normal opening hours	The advertised opening hours of a practice
Nurse	A registered nurse who can demonstrate competence in the provision of nursing care; a registered nurse practices independently and interdependently, and has accountability and responsibility for their own actions and the delegation of care to enrolled nurses and other healthcare professionals
Nurse practitioner	A registered nurse who is educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role where their scope of practice is determined by the context in which they are authorised to practice
Open disclosure	A method clinicians are encouraged to use in order to communicate with and support patients, their family, and carers who have experienced harm while receiving, or as a result of receiving, healthcare
Organisational chart	A description (often presented visually) of an organisation’s structure, which includes areas (eg departments, division, properties), hierarchies, roles, responsibilities and professional relationships between individuals
Other visit	A general practice consultation in a facility other than the general practice or the patient’s home (eg residential aged care facility)
Outside of normal opening hours	The hours other than the practice’s normal opening hours
Over-the-counter medicine	Medicines that people can purchase from retailers (such as pharmacies, supermarkets and health food stores) for self-treatment
Patient	A person who is seeking or receiving healthcare and in relevant circumstances, can also refer to a carer (eg if you need to explain treatment to a patient who has intellectual disability, you may also need to explain the treatment to the patient’s carer)
Patient centredness	Patient-centeredness places the patient's needs, values and preferences at the forefront of medical decision-making, empowering patients to take an active role in their own healthcare. Patient-centeredness is demonstrated by a general practice team’s understanding that health, illness and disease are ultimately personal experiences, and that the role of the team is to collaborate with patients to support their healthcare.
Patient health information	A patient’s name, address, Medicare number and any information (including opinions) about the patient’s health
Patient health record	Information, held about a patient, in paper form or electronic form, which may include: contact and demographic information medical history notes on treatment observations correspondence investigations test results photographs prescription records medication charts insurance information legal information and reports work health and safety reports
Performance monitoring	A formal and structured process used to monitor and document a team member’s performance in their role
Personal protective equipment (PPE)	Equipment used to prevent and control infection, including appropriate gloves, waterproof gowns, goggles, face shields, masks and footwear
Position description	A document describing a team member’s role, responsibilities and conditions of employment
Practice management	The strategic planning, reviewing and implementation of processes that increase a practice’s efficiency and contribute to ‘excellence in healthcare’
Practice team	All people who work or provide care within the practice (eg GPs, receptionists, practice managers, nurses, allied health professionals)
Practice team member	An individual member of the practice team who provides care within the practice (eg a GP, receptionist, practice manager, general practice nurse, allied health professional)
Practitioner/clinician (refer to Clinical team)	A member of the practice team who has health qualifications that qualify them to perform clinical functions
Qualified	Holding the educational or other qualifications required to perform a specific activity (eg administer first aid) or hold a specific role (eg GP, registered nurse)
Quality assurance	The maintenance of a desired level of quality in a service or product, especially by attending to every stage of the process of delivery or production
Quality improvement	One or more activities undertaken by a practice to monitor, evaluate, or improve the quality of healthcare it delivers
Recall	The process of requesting a patient to attend a consultation to receive further medical advice on matters of clinical significance
Referral	The process of sending or directing a patient to another practitioner
Relevant family history	Information about a patient’s family history that the practitioner considers important in order to provide appropriate clinical care to the patient
Respiratory etiquette	Public health measures used to reduce the spread of respiratory infections (ie encouraging people to cover their mouth or nose when coughing or sneezing, use tissues to blow their nose, dispose of used tissues, and wash their hands after touching their nose)
Risk	An event or set of events that, if they occurred, would adversely affect the achievement of objectives
Risk management	Systematic application of principles, approaches and processes to: identify, assess and minimise risks plan appropriate responses implement appropriate responses when required
Risk matrix	A matrix used to categorise risks according to their probability and the severity of the effects they would cause
Risk register	A document used to record problems and issues that could result in a risk becoming a reality, and the steps taken to minimise the likelihood or effect of the risk
Safe and reasonable	A desired description of the outcome of a clinical care decision made by a practice that was based on relevant factors (eg the practice’s location and patient population) and an understanding of what their peers (or practices in the same area) would agree was safe and reasonable
Safety	The condition that means potential risks and unintended results are avoided or minimised
Schedule 8 medicines	Drugs that have a recognised therapeutic need and are legally available only by prescription because they are drugs of dependence and therefore have a higher risk of misuse and abuse
Screensaver	A software program that displays constantly changing images or dims the brightness of a display screen. It is used to: protect the screen from having an image etched onto its surface restrict unauthorised access to the computer, and the information displayed on the screen before the screensaver begins
Security	The administrative, technical and physical safeguards in an information system that protect it and its information against unauthorised disclosure, and limit access to authorised users in accordance with an established policy
Server	A computer that provides services to users connected to the network running the server. Services can include printing, access to files and software applications, and central storage of data
Sex	A person’s assigned sex at birth, determined by sex characteristics observed at birth or infancy. A person’s sex can change over the course of their lifetime and may differ from their assigned sex at birth
Sex characteristics	A person’s chromosomal, gonadal and anatomical characteristics associated with sex
Sociable hours	The after-hours period from 6.00–11.00 pm on weeknights
Social media	Online social networks used to disseminate information through online interaction
Standard precautions	Methods and practices that health professionals use to prevent infection of themselves and others, based on the assumption that all blood and body fluids are potentially infectious
Sterile	A condition characterised by the absence of protozoa, spores, mycobacteria, fungi, Gram-positive and Gram-negative bacteria, chlamydia, Rickettsia, mycoplasma and viruses
Sterile barrier system	The packaging for items placed in a steriliser
Sterilisation	A validated process used to render a product free from all forms of viable microorganisms (the nature of microbial death is described by an exponential function, and although the probability that all microbes have died can be reduced to a very low number, it can never be reduced to zero)
Strategy	A method or plan for an organisation to achieve its short-term, medium-term, and longterm goals
Telehealth	The use of telecommunication techniques for the purpose of providing telemedicine, medical education and health education over a distance. Telehealth services use information and communications technologies to deliver health services and transmit health information over both long and short distances. It is about transmitting voice, data, images and information
Telephone triage	A method of determining, over the telephone, the nature and urgency of problems and providing directions in order to achieve the required level of care
Timely	Within an appropriate period for the given situation, as might reasonably be expected by professional peers
Tracking and tracing	Part of a sterilisation process that refers to batch control identification of instruments used for a procedure on a patient
Trans and cis	‘Trans’ and ‘cis’ are terms that describe the experience or modality of gender (and are used as prefixes to gender, ie transgender and cisgender), rather than a gender label itself. The trans experience occurs when an individual’s gender differs from that presumed for them at birth. The cis experience occurs when an individual’s gender is the same as what was presumed for them at birth
Transmission-based precautions	Methods and practices that health professionals use to prevent infection of themselves and others, when a patient is known or suspected to be infected with a highly transmissible infection such as influenza and when standard precautions may not be sufficient to prevent infection. Transmission-based precautions include droplet precautions, airborne precautions and contact precautions, and involve the use of appropriate measures such as triage, PPE and isolation
Triage	Patient prioritisation based on where resources can be best used or are most needed
Unsociable hours	The following after-hours periods: Weekdays – 11.00 pm – 8.00 am Saturdays – before 8.00 am and after 12.00 pm Sundays and public holidays – any time
Urgent	Requiring immediate action or attention
Values	Principles that stipulate how the organisation and the practice team are expected to behave
Vision	A declaration of an organisation’s objectives
Whole-person care	Holistic care is reflected in the interplay between bio-psycho-social contributors to health, and which leads to a deep understanding of the whole person, and the ability to manage complex conditions and circumstances. A general practitioner (GP) functions as a physician, counsellor, advocate and agent of change for individuals, families and their communities.

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