Accreditation and Electronic Medical Records
The release of the current (third edition) RACGP Standards for General Practices (Standards) imposes a number of additional requirements for medical records systems that many practices, both large and small, will find challenging and problematic. This series of articles seeks to provide a framework to support practices through the maze of standards criteria relating to medical records and particularly electronic records.
Essentially the requirements of the Standards relating to medical records can be grouped into three main areas. These are:
- Specific content requirements for electronic health records.
- Administrative requirements including those for maintaining security and privacy.
- Additional evidence based requirements used to assess compliance with the standards.
This first article discusses the structure of the standards in general and details the content based requirements.
Structure of the Standards
The current Standards are divided into five sections, namely:
- Practice Services
- Rights and Needs of Patients
- Safety Quality Improvement and Education
- Practice Management
- Physical Factors
Within each section are a number of Standards, Criteria and Indicators:
- Standards are a broad description or statement of intent regarding key aspects of quality in the practice.
- Criteria detail key components of the Standard
- Indicators provide a basis for measurement.
Medical Records & RACGP Standards
| Compliance Indicators|
|1.1.2||Telephone and electronic advice|
|1.1.3||Home and other visits|
|1.1.4||Care outside normal opening hours|
|1.3.1||Health promotion and preventive care|
|1.4.1||Evidence based practice|
|1.5.1||Continuity of care|
|1.5.2||Continuity of therapeutic relationship |
|1.5.4||System for follow up of tests and results|
|1.6.1||Engaging with other services|
|Content Of Patient Health Records|
|1.7.1||Patient health records|
|1.7.3|| Consultation notes|
| Management Of Health Information|
|4.2.1|| Confidentiality and privacy of health information|
|4.2.2|| Information security|
|4.2.3|| Transfer of patient health information|
|4.2.4|| Retention and destruction of patient health information|
This table identifies key criteria relating to medical records and health information. These include content requirements for patient health records, requirements for the management of health information and criteria where the medical record is used as an indicator or assessment tool to ensure that criteria is met.
Specific Content Requirements
Criterion 1.7.1 requires that all patients have an individual health record containing all clinical information held by the practice relating to that patient. Medical records systems may be almost entirely electronic, paper based or a hybrid. Increasingly practices are taking the plunge and moving totally electronic. Personal experiences with the changeover vary but an individual written practice based strategy prior to implementation for the practice is a good idea to ensure all doctors and staff have consistent objectives, prevent loss of data and support a seamless transition.
Specific elements of the medical records include basic patient demographic information, health summaries consultation or progress notes, referral documents and results of investigations or referrals.
As well as the name, age, gender and contact details the current Standards now require that the practice is actively collecting details of the cultural background of patients, including Aboriginal and Torres Strait Islander self identification and contact in case of an emergency.
The current Standards now require that at least fifty percent (50%) of active patient records contain a health summary and ninety percent (90%) of these records containing a record of allergies in the patient health summary (Criterion 1.7.2).
The following are content requirements for health summaries:
- Current problems
- Past history
- Medications including drug, dose and frequency
- Risk factors including smoking, alcohol and other drugs
- Relevant family history
- Relevant social history
The optimum approach is to upgrade health summaries as each patient presents. Practice support and administrative staff might ensure that demographic and contact details are current and each doctor should ensure that other details are current and complete. Depending on circumstances the patient may need another consultation to enable all information to be collected and this may be undertaken in conjunction with a patient care plan, aged health assessment or consultation with a practice nurse.
A record of every patient encounter including after hours consultations, home or other visits and telephone encounters should be kept. Some electronic medical records systems allow for off site recording and synchronisation of records but many do not have this facility. How the practice handles the recording of these consultations is an important issue for accreditation.
Consultation notes should identify date and provider and include the following details for all patient encounters:
- Reason for presentation.
- History of present illness including symptoms, onset, site, precipitating and relieving factors and time present.
- Systems review including significant negative findings.
- Relevant past history, social and family history if not already recorded.
- Examination findings including significant positive and negative findings.
- Problem list or diagnosis.
- Management plans including treatment prescribed, investigations ordered, referrals for specialists and other health providers, preventative and other health advice provided.
The Standards now also require evidence that problems raised in previous consultations are followed up and management plans reviewed.
Referral letters are one of the Achilles heels of electronic medical records systems. There is a growing use of templates that document all medication and previous history but unfortunately much of this information is either irrelevant because the current health summary or medication list are not kept up to date. The end result can be a referral letter with significant amounts of garbage in and garbage out.
The referral letter, particularly for complicated problems, can be viewed as another opportunity to review the patient, their problems and context. Often the referral letter is the only way in which our colleagues can have a basis for viewing us professionally. Copies of all significant referrals are generally maintained in the electronic medical records system and these should include:
- Reason for and expectation of the referral.
- History of presenting problem.
- Relevant positive and negative findings on examination.
- Results of investigations.
- Management including current medications.
- Significant past, Social and family history.
High quality, comprehensive medical records are crucial for maintaining patient care and improving risk management. As practices make the change from paper based or hybrid systems to electronic records systems they can take the opportunity to ensure that records are updated to reflect standards requirements for content, confidentiality, administration and security.
Posted in Australian eHealth