Accreditation practice pointer: patient health records

C7.1 A Our practice has an individual patient health record for each patient, which contains all health information held by our practice about that patient.

RACGP Standards for general practice.

Patient health records that provide all required patient health information and legible notes of each patient interaction help GPs provide optimum primary healthcare and practice at the top of their scope.  According to medical defence organisations, neglecting to follow up any concerns raised by patients is a risk to practices and practitioners. 

General practices can ensure that patient health records are complete through the following actions:

• maintain a policy addressing the management of patient health information

• ensure handwritten records are legible

• ensure new patient forms ask for all required information

• cover policies and processes relating to patient health records during staff inductions.