Accreditation practice pointer: patient health records
C7.1 C Our patient health records include records of consultations and clinical related communications.
RACGP Standards for general practice
Accurate and thorough patient health records allow other clinicians to assume patient care, should it be necessary. Each patient health record must clearly detail all clinical information relevant to the patient.
Therefore, consultation notes must contain the following information:
Date of consultation
Who conducted the consultation (eg by initials in the notes, or by audit trail in an electronic record)
Method of communication (eg face to face, email, telephone or other electronic means)
Patient’s reason for consultation
Relevant clinical findings including history, examinations and investigations
Allergies
Diagnosis (if appropriate)
Recommended management plan and, where appropriate, expected process of review
Any medicines prescribed for the patient (including the name, strength, directions for use, dose, frequency, number of repeats and date on which the patient started/ceased/changed the medication)
Patient consent for the presence of a third party brought in by the practice (eg a medical student)
Record of patient emails (if applicable)
General practice can ensure consultation notes are completed correctly by maintaining a policy addressing the management of patient health information.
