Accreditation practice pointer: patient health records have a current health summary

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

RACGP Standards for general practice

Thorough patient health records provide general practice clinicians with an overview of all necessary elements of a patient’s care, which consequently enables them to provide optimum care.

 An active patient’s current health summary must include, 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.

General practice can ensure this Criterion is met conducting a regular audit of patient health records.