GP health summaries – clear guidelines needed to ensure consistency
4 February 2011. A need to clearly define the key elements of the GP health summary and its application in an electronic health record has prompted the Royal Australian College of General Practitioners (RACGP) to develop a set of seven factsheets to provide advice to general practice and their teams.
The 4th edition of the RACGP Standards for general practices requires that practices can demonstrate that at least 75 percent of their active patient health records contain a current health summary (criterion 1.7.2). To meet the requirements for a satisfactory summary, elements such as allergies and adverse reactions, current medicines list, current health problems, relevant past health history, health risk factors, immunisation, relevant family history and relevant social history need to be included. But what does ‘current’ or ‘relevant’ mean?
RACGP e-health spokesperson Dr Chris Mitchell said that there is a need to clearly define the core elements of the GP health summary as health information available through an accurate and current health summary will ensure safe and high quality care for patients.
“In the complex heath systems we work in, teamwork is essential and everyone in the team needs a shared understanding of what a health summary should include. These factsheets are a useful resource for the whole general practice team to increase patient safety and better continuity of care and will also be valuable for the wider primary care and hospital sector,” he said.
NEHTA’s National Clinical Lead, Dr Mukesh Haikerwal, said it was highly likely that the GP health summary will form the basis of clinical information for electronic communication between healthcare providers and therefore be a key component for electronic health records with the roll-out of the PCEHR.
“We know that GPs can provide a GP Health Summary for the vast majority of Australians so it makes practical sense that this information is used when developing content for the PCEHR,” said Dr Haikerwal
The full media release can be accessed via http://www.racgp.org.au/media2011/41154
