Accreditation practice pointer: our patient health records include consultations and communications
C7.1 C Our patient health records include records of consultations and clinical related communications.
RACGP Standards for general practice
A complete patient health record supports sound clinical decision making. Furthermore, medical defence organisations have indicated that clinicians who do not follow up on matters raised by patients may be exposing themselves and the practice to legal consequences. Practices can support the Criterion by maintaining a policy on the management of patient health records.
Thus, consultation notes must include the following:
Date of consultation
Who conducted the consultation
Who is present at the consultation (including carer)
Method of communication
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
Patient consent for the presence of a third party brought in by the practice (eg a medical student)
Record of patient emails (if applicable).
any referrals to other healthcare providers or health services
Patient health records might also include:
medicines that were not prescribed or advised by the practice
any relevant preventive care information collected, such as currency of blood pressure, waist measurement, height and weight (body mass index)
an advance care plan.
Practices need to ensure all documents scanned into electronic health records are legible. If not, make appropriate notes clarifying the information