Accreditation practice pointer: Current Health Summary

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

RACGP Standards for general practice.

A current and accurate health summary supports the delivery of safe and quality care by providing clinicians an overview of a patient’s health.

Ultimately, health summaries:

  • reduce the risk of inappropriate management, including medicine interactions and side effects (particularly when allergies are recorded)

  • provide an overview of social circumstances and family history that is vital to holistic care

  • highlight lifestyle and risk factors (eg smoking, nutrition, alcohol, physical activity) that can help practitioners to promote healthy lifestyles

  • highlight risk factors associated with chromosomal, gonadal and/or anatomical characteristics (particularly when a patient’s gender identity and assigned sex at birth are different, or a patient advises they have innate variations of sex characteristics)

  • help prevent disease by tracking immunisation and other preventive measures.

A 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 support the maintenance of accurate health summaries by conducting a regular audit of patient health records.

Margot Schoonmaker