RACGP releases new guide to improving the quality of health records

Doug Hendrie

7/11/2018 2:10:04 PM

High-quality clinical data has a raft of benefits, from decision-making to medico-legal protection, according to Dr Rob Hosking.

eHealth expert Dr Rob Hosking believes a large part of ensuring quality patient data is ‘a matter of getting in the habit’.
eHealth expert Dr Rob Hosking believes a large part of ensuring quality patient data is ‘a matter of getting in the habit’.

Say the words ‘data’ and ‘quality’ together, and you would be forgiven if your eyes glazed over just a little.  
But ensuring the data GPs input into their practice software is of high quality helps to support appropriate clinical decision-making and continuity of care. And good record-keeping is a vital part of medico-legal protection, according to Dr Rob Hosking, Chair of the RACGP Expert Committee Practice Management and Technology.
‘Good record keeping is important for being able to defend yourself in a medico-legal case. Anyone who’s ever been in a medico-legal case will say, “I wish I’d written more”,’ he told newsGP.
Dr Hosking believes high-quality data has many clinical, practical and research benefits.
‘It’s a matter of getting in the habit. If you do it as you go, you find it pays dividends later,’ he said. ‘If you’re writing a referral and you automatically merge patient information, it makes it a lot easier if it’s high quality.’
The RACGP has recently published a new guide, Improving health record quality in general practice, designed to help GPs maintain quality records.
Dr Hosking said the guide covers what constitutes high-quality patient health information, as well as systems and processes practices can introduce to ensure records are of a strong standard.
The importance of good data is also in the spotlight ahead of the end of the My Health Record opt-out period on 15 November, with uploaded patient Shared Health Summaries to be more easily available to other healthcare professionals.
‘No longer serving only individual [GPs] or practices, information in a patient’s health record is likely to be shared between and relied upon by primary, secondary and tertiary healthcare services,’ the RACGP guide states.
‘For patients, the quality of their health information kept by a practice can affect their healthcare outcomes, as it informs decisions about their treatment and facilitates continuity of care, both within the practice and between other services. High-quality records also make it easier for patients to access and understand their healthcare information.
‘For individual GPs, high-quality health records allow them to effectively communicate with their colleagues and other health professionals. They allow GPs to take full advantage of clinical information systems to more efficiently manage patient follow-up – through reminders or recalls – for particular patient populations.’
The guide states that good data permits a practice to undertake quality improvement projects, and to understand its own patient cohort and more readily target specific groups.
Dr Hosking said quality data also makes it much easier for colleagues to manage another GP’s patients while they are on leave. He recommends un-checking ‘new problem’ as the default reason for a patient’s attendance in clinical software.
‘If you leave it as the default, you get a list a mile long of reasons for consultation, and that clutters things up,’ he said.
Dr Hosking recommends using the single-use medication button wherever possible, as it means the medication will drop off the list and won’t ‘clutter up’ the patient’s history.

data quality medico-legal my health record

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