If the practice uses more than one digital clinical information system, the complete details of all patient consultations do not need to be duplicated in both systems, but each system does need to include:
- up-to-date patient health summaries (such as the same in each record) so that all pertinent information, including allergies and medications, is available in any system at any time. See CG3 – Facilitating complete patient health records for further information about records of each consultation and interaction in each patient health record, which also needs to include where the clinical notes are recorded.
If the practice uses more than one digital clinical information system, the record of each consultation or interaction could include:
- a note in the practice’s clinical information system, notifying users that a consultation or interaction has occurred, and where to find the full details of that exchange
- a billing record to show where the consultation occurred (for example, the clinic, via telehealth).
The practice could also develop a policy or process addressing the use of the digital clinical information systems, how information is stored in each system and where to find relevant information.
It is good practice to:
- inform all practitioners in the practice, including locums, that multiple digital clinical information systems are being used and that they need to look at both systems to access all relevant information
- make the required information in both systems readily available
- include a clearly visible note stating that the practice uses a hybrid digital patient health record system and where information is recorded.