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.

Other Toolkits

The Royal Australian College of General Practitioners acknowledges Aboriginal and Torres Strait Islander peoples as the Traditional Custodians of the land and sea in which we live and work, we recognise their continuing connection to land, sea and culture and pay our respects to Elders past, present and future.