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 - may select woman as her gender ‘M’ and as her sex on a form and not identify themselves as transgender. Similarly, intersex people ‘F’ 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)
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)
RACGP-Standards-for-after-hours-service-consultation-draft-August-2017.docx