Accreditation practice pointer: patient health records

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

RACGP Standards for general practice, 5th edition.

Active patient health records support clinical decision making, and so must be current and accurate. Patients must match their respective health record to ensure optimum treatment. Indeed, there can be catastrophic results when patients are aligned with the incorrect health record.  

Practices can meet the Criterion by maintaining a policy on the management of patient health information. The policy might stipulate new patients complete a form that asks for the required information, as per the Indicator.

Likewise, longstanding patients can also complete a form at regular intervals to ensure all their identification details are up-to-date. Patients can change addresses, phone numbers and next of kin, for example, and so it is important general practice updates their health record accordingly.