Consider updating medical software when practicable (so that files do not become incompatible). This will help protect against the possibility of superseded versions of medical software not being able to run properly on more modern hardware and operating systems. You may need to consider retaining older hardware and operating systems so that you can store and retrieve older records. Collecting information from patients Practices can collect information from a new patient using a generic form, on paper or electronically, or by privately interviewing patients before the first consultation. You must have a system that ensures that patient information (including the contact details of their emergency contact) is updated regularly so that it remains accurate. Practices need a patient identification process to ensure that the right patient is matched to the right record and is therefore receiving the right treatment. LGBTQIA patient demographic information LGBTQIA data collection methods often do not distinguish between the labels people use about themselves and the labels other people might use about them. For example, people who are classified as transgender by others may self-identify simply as women or men. Someone who was assigned male at birth and whose documents list her sex as ‘M’ - may select woman as her gender and ‘F’ as her sex on a form and not identify themselves as transgender. Similarly, intersex people may select male or female as their sex rather than nominating themselves as intersex. You practice could do the following to improve the accuracy of responses when collecting information from LBGTQIA patients: use anonymous collection methods clearly articulate how answers will be utilised and why they are being asked have the ability to select more than a single option and provide more than one response ask questions that distinguish between identity and descriptors of behaviour/ attraction/ experience. Content of patient health records Patient health records must be updated as soon as practicable during or after consultations and visits. The record must identify the person in the clinical team making the entry. All patient health records, including of external reports, must be legible so that another practitioner can take over the care of the patient. Consultation notes must contain the following information: date of consultation who conducted the consultation (e.g. by initial in the notes, or by audit trail in an electronic record) method of communication (e.g. face-to-face, email, telephone or other electronic means)
Clinically significant information may include the patient’s health and goals, preventive health activities, medical conditions and their preferences and cultural values. Having this information improves your ability to provide care that is tailored to the patient’s needs and circumstances. Identifying patients of Aboriginal and Torres Strait Island origin, or another cultural background Practices are encouraged to identify and record the Aboriginal and Torres Strait Islander status and cultural background of all patients, as this information can be an important indication of clinical risk factors and can help practitioners to provide relevant care. Practices must ask all patients the following question, regardless of the patient’s appearance, country of birth, or whether the practice team know of the patient or their family background: ’Are you of Aboriginal and/or Torres Strait Islander origin?’ Be mindful that some patients may indicate that they do not wish to answer the question. In this case the response would be ‘Not stated / inadequately described’. A missing response on a returned form should be followed up immediately and should not be automatically regarded as a refusal to respond. All patients have the right to respond to this question as they see fit. The patient’s response should be received without question or comment, and the response should be recorded without any amendments or annotations[]. Before asking this question, or any questions relating to a patient’s cultural background, explain that knowing such information helps the practice provide appropriate healthcare. Collecting this information before a consultation, such as from a new patient form assists you to provide the most appropriate care. Depending on where patients were born, where they grew up or where their parents are from, some patients may be at higher risk of certain health conditions. Information relating to the patient’s ethnicity, country of birth, and language spoken can help to identify patients who require specific care or targeted interventions. It is good practice to record this information in the patient health record if it is relevant to patient care. Retaining health records of active and inactive patients Your practice must keep and securely and dispose of health records of active and inactive patients in accordance with legal obligations imposed by the Privacy Act 1988 and the APPs. An inactive patient is generally defined as a patient who has not attended the practice/service more than twice in the past two years. It is recommended that you retain inactive patient health records as required by relevant national, state or territory legislation. You may want to consult your medical defence organisation when deciding on the practice’s policy on the retention of records of inactive patients. Lifestyle risk factors