RACGP: Quality health records in general practice

Summary of key concepts

  • “Sufficiently complete”
    • Enough detail to support safe care and the record’s purpose.
    • Completeness requires a judgement about what matters.
  • “Relevant history, examination and investigations”
    • Relevance is determined clinically.
    • Every possible detail does not carry equal weight.
  • “Diagnosis where appropriate”
    • Recognises that a diagnosis may remain uncertain or emerge over time.
  • “Reasons recommended care was not offered or provided”
    • Allows for justified departures from recommendations, with the reasoning documented.
  • “Clear supporting narrative”
    • Preserves context, uncertainty and reasoning that structured fields alone may not convey.
  • “Write for other readers”
    • The aim is an understandable clinical account that helps the next clinician.
  • “General guidance cannot cover every circumstance”
    • Acknowledges the limits of universal rules when applied to individual patients.
  • “Apply professional judgement”
    • Explicitly requires the clinician to interpret and apply guidance to the circumstances.
  • “Following recommendations alone does not establish that duty of care has been met”
    • Completing the prescribed steps is not, by itself, proof of adequate care.
  • “Does not replace clinical assessment”
    • Documentation supports the practice of medicine; it cannot substitute for the assessment itself.

Tick boxes provide structure and help prevent omissions. The art lies in deciding what is relevant, recognising uncertainty, adapting care to the individual and explaining significant decisions.

The standard is a record that communicates the clinically important story clearly enough to support care. More boxes and more words do not necessarily achieve that.

1. Introduction

  • Good records support safe care, clinical decisions, continuity, audits and practice improvement.
  • Records may be shared with other clinicians or used for research, education, policy and legal purposes.
  • Keep information accurate, complete and current. Clear documentation is a professional responsibility under Ahpra’s code of conduct.
  • Make record keeping routine, supported by leadership, training, policies and practical systems.
  • The guide helps practices improve documentation but does not provide legal advice.

2. Why quality matters

Primary purposes

  • Guide diagnosis, treatment and follow-up.
  • Document care and coordinate it across healthcare settings.
  • Provide reliable evidence for clinical safety, legal matters and patient access.

Secondary purposes

  • Support audits, improvement, financial viability, planning and governance.
  • Contribute to public health, research and policy.

Sharing, privacy and consent

  • Expect other clinicians, patients and third parties to read records.
  • The guide calls for informed consent before disclosure, with exceptions for serious threats to life, health or safety and legal requirements.
  • My Health Record generally requires no separate consent for each upload.
  • Respect requests against uploading particular information.
  • Follow jurisdictional rules for sensitive information, including those in NSW, Queensland and the ACT.

Interoperability and population health

  • Accurate, consistent data reduces information gaps and errors between systems.
  • Reliable records identify groups for targeted care and research and support trust.

3. Benefits of quality health records

For GPs

  • Support automated recalls, reminders and timely information sharing.
  • Preserve evidence of care and provide data for audits.
  • Reduce reliance on memory, unnecessary investigations and duplicated work.
  • Enable checks for medicine interactions, allergies and contraindications.

For practices

  • Identify patient groups needing targeted services.
  • Improve clinical and administrative workflows.
  • Guide planning, management and service development.
  • Match staffing and equipment to patient needs.

For patients

  • Improve treatment decisions, continuity and safety.
  • Help patients understand their health and participate in treatment choices.
  • Provide a fuller health history and better coordination between providers.

For the community

  • Improve referrals, communication and transfers of care.
  • Help services respond to population health needs.

4. AI scribes and data quality

  • AI scribes turn consultation conversations into draft notes, summaries or letters.
  • GPs must review the output and correct errors or inconsistencies.
  • Obtain consent at the start of the consultation and document it.
  • Many scribes produce narrative notes without populating structured fields.
  • Check that observations, allergies and adverse reactions are entered in the appropriate fields.
  • Structured data supports medication lists, decision support, analysis and research.
  • A complete narrative does not guarantee a complete clinical record.

5. Creating quality health records

Readable

  • Use clear language, legible scans and clear layouts; avoid personal shorthand.
  • Review notes with colleagues and write for other readers.
  • Software familiarity and typing skills affect readability; AI scribes may help.

Current

  • Record consultations and incoming information promptly.
  • Allow maintenance time and use reminders to update lifestyle information.

Complete

  • Record the date, clinician and consultation method.
  • Document consent for AI scribes and third parties brought in by the practice.
  • Include presenting concerns, relevant history, examination and investigations.
  • Record diagnosis where appropriate, management and review arrangements.
  • Include medicine names, strengths, doses, directions, frequency, repeats and start, stop or change dates.
  • Explain why recommended care was not offered or provided.
  • Use registration forms, clear procedures and assigned follow-up responsibilities.

Accurate

  • Confirm patient identity, identifiers, contact details and the correct record.
  • Check consultation information and material received from elsewhere.
  • Restrict changes to authorised, trained staff and review near misses.

Consistent

  • Use recognised terminology, structured fields and clear supporting narrative.
  • Train staff and standardise abbreviations, templates and shortcuts.
  • Link templates to record fields.
  • Consistent coding supports searches, audits, population care, alerts and information exchange.

6. Additional resources

  • AHPRA / Medical Board: professional conduct and good medical practice.
  • Australian Commission on Safety and Quality in Health Care: health service standards.
  • Australian Digital Health Agency: practice management software.
  • Office of the Australian Information Commissioner: collecting health information.

7. Publication information

  • First published: October 2018.
  • Last substantial update: November 2025.

8. Disclaimer

  • General guidance cannot cover every circumstance; apply professional judgement and seek advice when needed.
  • Following recommendations alone does not establish that duty of care has been met.
  • The guide does not replace clinical assessment, medical history, diagnosis or treatment.
  • RACGP disclaims liability for losses arising from reliance on the publication.
  • The licence requires attribution and prohibits editing, adaptation and commercial use.
  • The publication acknowledges Traditional Custodians and Elders.