CG3 – Facilitating complete patient health records

Maintaining accurate and comprehensive patient health records is a crucial element in the provision of continuity of safe, high-quality care and compliance with privacy laws.

The RACGP has developed the Improving health record quality in general practice guide which outlines what constitutes a high-quality health record and how practices could put systems in place so they produce health records that are fit-for-purpose.

In addition, it’s important to accurately and objectively document information related to family, domestic and sexual violence (FDSV) and child sexual abuse. These records may be used in legal proceedings, therefore current and factual information supports patient safety, confidentiality and continuity of care.

Using a nationally recognised medical vocabulary in codable fields allows the practice to collect structured clinical data that can be used to:

• track care over time, both for individuals and the patient population
• identify necessary quality improvement activities
• collect benchmarking data for comparison with other practices.

Codable fields are structured areas within the clinical information system that allow patient information to be recorded in a standardised, searchable format that uses clinical coding systems rather than free text.  

This allows information to be consistently recognised, supporting clinical decision-making, continuity of care and quality improvement, as well as retrieval and use in the system.

To support the effective use of codable fields in the patient health summary, the practice could: 

• include the use of codable fields as part of induction or ongoing support for clinicians when introducing or upgrading clinical information systems. 
• provide guidance to the clinical team on which parts of the clinical information system are used for recording coded health summary information 
• align workflows and documentation processes with how the clinical information system is designed to record and store coded information
• use system reports, prompts or audits (where available) to support identification and improvement of missing or incomplete coded health summary information 

Patient information may be collected through a range of sources, including online booking systems or patient-facing applications, registration forms or questionnaires. Where information is collected outside the clinical information system, relevant details need to be accurately transferred into the patient health record and recorded in codable fields where appropriate.

Patient details (including the contact details of their emergency contact) need to be kept up to date. The practice could do this by:

• having a prompt sheet for members of the practice team to ask patients if their details have changed each time they contact the practice or book an appointment
• using automated systems (for example, a patient portal) to prompt patients to update their information.

As many people use and are referred to by a name that may differ from some or all of their identity documents, the practice needs to record all names that the patient calls themselves, as well as the name recorded on official documents. Individual Healthcare Identifiers are based on the name registered with Medicare.

Members of the practice team are legally required to collect, handle, store and share all personal and sensitive patient information in accordance with applicable privacy laws. See F9 – Confidentiality and privacy of health and other information for more information.

The practice needs 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.

Consistent recording of these details helps improve clinical care by enabling:

• a better understanding of a patient’s experiences and beliefs (for example, if they a member of the stolen generation, have cultural obligations, or participate in cultural activities that contribute to their wellbeing)
• access to local care co-ordination services
• correct recommendations relating to immunisations
• appropriate recommendations for preventive healthcare interventions.

For those of Aboriginal and Torres Strait Islander origin, it also enables:

• participation in the Closing the Gap Pharmaceutical Benefits Scheme (PBS) co-payment measure
• access to particular medications on the PBS
• access to particular Medicare Benefits Schedule (MBS) item numbers and subsequent follow up by practice nurses, Aboriginal and Torres Strait Islander Health Practitioners and allied health services.

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

Every patient has the right to respond to this question as they see fit.

The patient’s response needs to be received without question or comment, and their response recorded without any amendments or annotations³¹.

If a patient indicates that they do not wish to answer the question, record ‘Not stated/inadequately described’. However, if the patient does not answer this question when it is on a form, follow up immediately in case they missed it by mistake, rather than assume that the patient has refused to answer.

The practice could record each patient’s ethnicity and their country of birth if this is relevant to their care. In some circumstances, there may be direct genetic health risks or religious beliefs that affect health decisions.

For further information about providing culturally safe and respectful care to Aboriginal and Torres Strait Islander patients and diverse populations, see PP3 – Respectful, culturally appropriate and culturally safe care.

Patient health records are most useful when they are clear, contemporaneous and provide enough detail for another clinician to understand the patient’s situation and continue care if required.

Records need to contain sufficient information to accurately document consultations and clinical-related communications. They also capture clinical‑related communications that occur outside formal consultations where this information is relevant to the patient’s care, safety or continuity of care.

This includes:

• an initial assessment documented at the first consultation, including relevant history, presenting concerns and clinical findings, to establish a baseline understanding of the patient and support safe and appropriate care planning
• documenting sufficient detail for each consultation and clinical-related communication (including advice, follow‑up or information provided outside a consultation) to support safe clinical decision-making and continuity of care
• additional details collected during subsequent consultations, including matters that have been followed up from previous consultations, as the clinical team builds a relationship with the patient.
• relevant safeguard information provided by the patient or a lawful authority, where this information is necessary to support safe communication, continuity of care, or risk management for the patient or others.

A current and accurate health summary supports clinical decision-making, continuity of care and effective use of the clinical information system. A patient’s health summary includes a range of coded information, such as current and past health problems, medicines and allergies, immunisations, health and lifestyle risk factors, family history and social history.

To support the currency of patient health summaries, the practice could:

• use system prompts to support clinicians to update coded information when new diagnoses, risks or treatments are identified
• use system prompts or review tools to identify records where key health summary fields are incomplete or outdated
• support consistent use of the clinical information system through guidance, templates or agreed workflows.

To support complete and reliable allergy documentation, the practice could:

• use system prompts or alerts to flag records where allergy status has not been recorded
• require allergy status to be confirmed and recorded during patient registration, consultations, or routine record reviews
• record either a known allergy or ‘no known allergies’ in a codable field, rather than leaving the field blank
• include allergy status as part of routine data‑quality or record‑review activities
• confirm allergy status when medications are prescribed, reviewed or reconciled.

Keeping an accurate and current medicines list supports safe prescribing, continuity of care and communication with other healthcare providers. Members of the clinical team could do this by: 

• updating medicines at relevant patient interactions, including new prescriptions, changes or ceased medicines  
• recording sufficient detail (for example, medicine name, dose and frequency)  
• reconciling medicines when there are changes in care, such as after hospital discharge or specialist review.

The medicines list need to be included in referral letters and clinical correspondence to support coordinated care. Members of the clinical team could:  

• incorporate medication review and reconciliation into routine consultations  
• use clinical software prompts or workflows to support review of medicines  
• provide guidance on consistent recording and updating of medicines. 

Shared decision-making takes place during a consultation when the clinician and patient collaborate to make health decisions after discussing the evidence base, benefits and harms, and consideration of the patient’s preferences, values and circumstances⁶. Shared decision-making is applicable to most situations; however, it is particularly important when:

• evidence does not clearly support a particular option
• a preference-sensitive decision is needed (for example, the decision is heavily influenced by the patient’s preferences and values⁶.

To support shared decision‑making, the practice needs to provide members of the clinical team with access to information and resources that assist discussions with patients about treatment and care options.

The practice could:

• make decisionsupport tools, clinical guidelines or patientfacing information available to clinicians for use during consultations
• support clinicians to tailor discussions to the patient’s needs, preferences, health literacy and circumstances
• support the use of interpreters or culturally appropriate resources where required
• provide time, systems or workflows that enable meaningful discussion between clinicians and patients, particularly for preferencesensitive decisions.

Identifying and respecting patient preferences is central to shared decision-making and supports patient-centred care. When patients are actively involved in decisions about their care, it can improve understanding, engagement, adherence to treatment, and overall health outcomes. It also helps ensure that care is appropriate, acceptable and aligned with the patient’s individual circumstances.

Members of the clinical team identify and respect patients’ preferences or choices by:

• exploring the patient’s values, goals and concerns
• considering cultural, social and personal circumstances
• supporting patients to express their preferences and participate in decisions.

Documenting shared decision‑making supports continuity of care, transparency and coordinated care across the practice team. To support this, members of the clinical team could:

• provide prompts or fields in the clinical information system to record discussions, patient preferences and decisions.
• record that individual treatment plans are developed in partnership with the patient and/or caregiver, including agreed goals, treatment options and planned actions
• track how treatment plans are monitored over time, including progress toward goals, response to treatment and any issues identified during follow-up consultations
• update treatment plans in coordination with the patient and/or caregiver, including any changes to goals, treatments or follow-up arrangements, and ensure these updates are clearly recorded.

Members of the clinical team have professional obligations relating to care and treatment decisions. Good medical practice: a code of conduct for doctors in Australia outlines how practitioners are required to work with their patients, and with other healthcare professionals when coordinating patient care.

Practitioners’ registration includes obligations to comply with relevant legislation, including mandatory reporting requirements such as notifiable conduct under Ahpra’s National Law and applicable child protection or safeguarding laws.

Members of the clinical team need to discuss, provide information about and record key aspects of care decisions with patients to support informed decision-making and shared understanding. When discussing and providing information to patients, members of the clinical team could:

• explain the purpose, importance, benefits, risks and potential side effects of proposed investigations, referrals, diagnoses, treatment options and management approaches
• discuss reasonable alternatives, including the option of no investigation or treatment where appropriate
• provide patients with information about what to expect following an investigation, referral or treatment decision
• document that these discussions have occurred in the patient health record.

When providing information about the purpose, importance, benefits, risks and side effects of actions to a patient, their carer, family member or other support person, the member of the clinical team could:

• consider the patient’s physical, visual and cognitive capacities, as well as their health literacy (see PP1 – Information about the practice)
• use plain English and arrange interpreter service where required (see PP2 – Communications)
• tailor information
• provide online or paper-based resources, including factsheets and brochures from trusted and accessible sources
• use relevant tools and resources (for example, visual resources, decision-support tools)
• check the patient’s understanding using techniques such as the teach-back method
• encourage questions and provides opportunities for questions
• document which information resources they have given to the patient (for example by pasting the resource’s URL into the patient health record).

Patients may refuse a practitioner’s recommended course of action, including advice, procedure, treatment or referral to other care providers.

When a patient refuses recommended treatment, advice or a procedure, members of the clinical team could record:

• the refusal and the context in which it occurred
• the information provided to the patient, including risks and alternatives discussed
• any agreed actions, follow‑up or alternative management.

Recording communications with patients is essential to support continuity of care, patient safety and effective communication across the practice team. Accurate and timely recording ensures that relevant information is available to support follow-up, coordination of care and appropriate clinical decision-making by any member of the practice team.

Recording communications relies on the capacity of the practice’s clinical information systems (See CG1 – Clinical information systems), which support the practice team to record, store and access patient communications in a consistent and secure manner.

Members of the practice team need to record patient communications that are relevant to the patient’s care, including attempts to contact patients, patientinitiated contact, advice or information provided, and use of translation services.

To support consistent and reliable recording of patient communications, the practice could:

• provide clear guidance to the practice team about which patient communications are recorded in the patient health record
• promote consistent recording practices so that communications are documented in a way that can be understood by other members of the practice team
• support recording processes that maintain privacy, accuracy and accessibility of information for authorised users.

Members of the practice team need to accurately record and securely manage safeguarding information that may affect the safety, wellbeing or care of patients or their dependents, and this includes writing it in the patient’s health record, appointment notes or any platform the practice uses. Safeguarding information must be factual, current and securely stored to protect confidentiality and to support coordinated care.

The practice records, where relevant:

• domestic violence orders (DVOs), apprehended violence orders (AVOs), child protection or other court orders
• agreed safety plans, special requirements or alerts
• communications with external agencies, such as child protection and family violence services.

For children and young people, the practice notes:

• custody or parental access arrangements
• how these were verified.

Safeguarding information recorded to support safe communication and continuity of care includes, where relevant:

• a patient’s preferred or safest contact method
• restrictions on who may receive information
• restrictions on who may access information based on role (see F9 – Confidentiality and privacy of health and other information)
• privacy flags within the health record
• any agreed communication protocols or cautions provided by the patient or a lawful authority.

Records may be requested or subpoenaed. Entries made by any member of the practice team need to be factual, objective and limited to what is necessary for safe communication and continuity of care. This could include:

• recording facts or verbatim quotes rather than opinions or speculation
• being precise about dates, times and sources of information
• separating third‑party information and avoiding unnecessary detail
• avoiding emotive or judgmental language
• noting only safeguarding information relevant to safety or continuity (for example, preferred or safest contact method, restrictions on who may receive information, privacy flags, agreed communication protocols, or relevant court/protection orders)
• storing information securely and in line with the practice’s privacy policy.

The practice could record patients’ birth-assigned sex, gender and preferred pronouns. Refer to the RACGP’s fact sheet for guidance on collecting and recording information about patient sex, gender, variations of sex characteristics and sexual orientation.

The practice could do the following to respect patients’ privacy when collecting this information from them:

• ensure all members of the practice team understand the importance and reasoning behind the sensitive collection of information about sex and gender
• in the patient registration form, clearly explain why these questions are being asked and how the answers will be used
• for each question, provide multiple options the patient can select from (preferred wording of questions and answer options can be found in the RACGP factsheet)
• with the patient’s permission, document their preferred pronouns when transitioning their care (for example, in referral letters)
• have a policy or process addressing the collection, storage and disposal of information about sex, gender, sex characteristics and preferred pronouns, and include information about how this information is collected, and which members of the practice team are best placed to request and discuss this information with patients.