Consultation notes
Criterion 1.7.3
Each of our patient health records contains sufficient information about each consultation to allow another doctor to carry on the management of the patient.
Indicators
| |
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| A |
Our patient health records document consultations - including consultations outside normal opening hours, home or other visits, telephone or electronic consultations where clinically significant - comprising:
Date of consultation
Patient reason for consultation
Relevant clinical findings
Diagnosis
Recommended management plan and where appropriate expected process of review
Any prescribed medications (including medicine name, strength, directions for use, dose, frequency, number of repeats, and date medicine started, ceased or changed)
Any relevant preventative care undertaken
Documentation of any referral to other health care providers or health services
Any special advice or other instructions
Identification of who conducted the consultation eg. by initials in the notes or audit trail in the record (health records review) |
| B |
Our patient health records show evidence that problems raised in previous consultations are followed up (health records review) |
| C |
The documentation of our patient health records includes:
The name and contact details of the patient?s usual GP; and
The time of consultation (health records review)
(Applicable only to after hours care and medical deputising services) |
Download RACGP criterion (PDF)
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