Standards for general practices

Quality improvement module

Criterion QI2.1 – Health summaries

        1. Criterion QI2.1 – Health summaries

Indicator


QI2.1 A Our active patient health records contain a record of each patient’s known allergies.

QI2.1 B Each active patient health record has the patient’s current health summary that includes, where relevant:

  • adverse drug reactions
  • current medicines list
  • current health problems
  • past health history
  • immunisations
  • family history
  • health risk factors (eg smoking, nutrition, alcohol, physical activity)
  • social history, including cultural background.

QI2.1 C Our active patient health records contain, where relevant, a record of each patient’s:

  • assigned sex at birth
  • variations of sex characteristics
  • gender.

Why this is important

Maintaining clear and accurate patient health records is essential if your practice is to provide high-quality care.3 A good health summary helps practitioners, locums, general practice registrars and students to obtain an overview of all components of the patient’s care in order to continue to provide safe and effective care.
Health summaries:

  • reduce the risk of inappropriate management, including medicine interactions and side effects (particularly when allergies are recorded)
  • provide an overview of social circumstances and family history that is vital to holistic care
  • highlight lifestyle and risk factors (eg smoking, nutrition, alcohol, physical activity) that can help practitioners to promote healthy lifestyles
  • highlight risk factors associated with chromosomal, gonadal and/or anatomical characteristics (particularly when a patient’s gender identity and assigned sex at birth are different, or a patient advises they have innate variations of sex characteristics)
  • help prevent disease by tracking immunisation and other preventive measures.

Meeting this Criterion

A patient’s health summary must give a practitioner sufficient information to enable them to safely and effectively provide care for the patient.

The RACGP encourages you to work towards all of your active records containing a current health summary, including a record of known allergies. However, to satisfy this Criterion, your practice must have a:

  • record of known allergies for at least 90% of your active patient health records
  • current health summary for at least 75% of your active patient health records.

If a patient has no known allergies, a practitioner must verify this with the patient and then record ‘no known allergies’ in the patient’s health record. If your practice uses a hybrid health record system, you must record the patient’s allergy status in whichever system is used for prescribing.

You could also record:

  • patients’ assigned sex at birth, variations of sex characteristics (intersex) and gender separately
  • aspects of a patient’s social history if this might increase their risk of health issues. For example, you might record a patient’s refugee status, where they live (eg urban, rural, remote), and information about their sexual partners and/or activity
  • recent important events in a patient’s life that could affect the patient’s preferences, values, and care they require (eg changes in accommodation, family structure, and employment).

It is good practice to ask patients if they are taking any medicines not prescribed by the practice or if they are using complementary therapies, and to record this information in their patient health record.

Meeting each Indicator

QI2.1 A Our active patient health records contain a record of each patient’s known allergies.

You must:

  • include records of known allergies in active patient health records.

You could:

  • keep records of when GPs ask patients about allergies.

QI2.1 B Each active patient health record has the patient’s current health summary.

You must:

  • keep a current health summary in each active patient’s health record.

You could:

  • conduct a regular audit of patient health records.

QI2.1 C Our active patient health records contain, where relevant, a record of each patient’s:

  • assigned sex at birth
  • variations of sex characteristics
  • gender.

You could:

  • record in each active patient health record the patient’s assigned sex at birth
  • record in each active patient health record whether the patient has variations of sex characteristics
  • record in each active patient health record the patient’s gender.

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