Attributes of high-quality health records
High-quality health records have six features. They are:
- Accurate – correctly reflects the patients details, information captured in consultation, and information collected from other sources.
- Complete – contains sufficient information, keeping in mind the ‘expect to share’ principle
- Consistent – uses a recognised medical vocabulary, standardised terms and abbreviations
- Legible – easily read and understood; written in a way that is meaningful to other users
- Accessible – data is recorded in ways that make it readily retrievable
- Up-to-date – updated in a timely manner.