status quo of quo vadis? - KCE

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120 Quality development in general practice in Belgium: status quo or quo vadis ? KCE Reports 76 Standard 1.7 - Content of patient health records CRITERION 1.7.1 PATIENT HEALTH RECORDS 1. There is evidence that each patient has an individual patient health record containing all clinical information held by our practice relating to that patient (health records review). 2. our patient health records are legible (health records review) 3. our active patient health records include contact and demographic information (where appropriate) including: • the patient's full name • date of birth • gender • contact details (health records review). 4. our practice can demonstrate that we are working toward recording the following information in our active patient health records: • self identified cultural background (eg. Aboriginal and Torres Strait islander self identification) • the person that the patient wishes to be contacted in an emergency (interview or health records review). CRITERION 1.7.2 HEALTH SUMMARIES 1. At least 90% of our active patient health records contain a record of allergies in the health summary (health records review). 2. At least 50% of our active patient health records contain a health summary. A satisfactory summary includes, where appropriate: • adverse medicines events • current medicines list • current health problems • past health history • risk factors • immunisations • relevant family history • relevant social history (health records review). 3. our patient health records show evidence that health summaries are updated to reflect recent important events (health records review). 4. if our practice uses both an electronic and paper based system for recording a patient's health summary, our practice can demonstrate how the patient's health information is made accessible (interview). CRITERION 1.7.3 CONSULTATION NOTES 1. 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
KCE Reports 76 Quality development in general practice in Belgium: status quo or quo vadis ? 121 • any prescribed medicine (including medicine name, strength, directions for use/ dose frequency, number of repeats, and date medicine started/ceased/changed) • any relevant preventive 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 initial in the notes, or audit trail in electronic record (health records review). 2. our patient health records show evidence that problems raised in previous consultations are followed up (health records review). Standard 2.1 - Collaborating with patients CRITERION 2.1.1 RESPECTFUL AND CULTURALLY APPROPRIATE CARE 1. our practice does not discriminate against patients on the basis of their gender, race, disability, Aboriginality, age, sexual preference, beliefs or medical condition (interview). 2. our GP(s) and staff who provide clinical care can describe how they provide care for a patient who refuses a specific treatment, advice or procedure (interview). 3. our GP(s) can describe what they do when a patient informs them that they intend to seek a further clinical opinion (interview). 4. our GP(s) can describe what they do to transfer care to another GP in our practice or in another practice when a patient wants to leave the GP's care (interview). 5. our GP(s) can describe arrangements for managing the transfer of care of a patient whom a GP within our practice no longer wishes to treat (interview). 6. our GP(s) and staff can describe how our practice provides privacy for patients and others in distress (interview). 7. our practice has used patient feedback to establish whether patients of our practice are treated respectfully by our GP(s) and staff (patient feedback). 8. our GP(s) and staff can identify important/significant cultural groups within our practice, and outline the strategies we have to meet their needs (interview). CRITERION 2.1.2 PATIENT FEEDBACK 1. our practice has a process for receiving and responding to feedback and complaints from patients and other people (document review). 2. our GP(s) and staff can describe the processes for receiving and responding to feedback and complaints from patients and other people (interview). 3. our practice makes contact information for the state/territory health complaints agency readily available to patients on request (interview, document review). 4. our practice has used patient feedback to establish whether patients of our practice are confident that any feedback and complaints they make to our practice would be handled appropriately (patient feedback). 5. our practice can describe an improvement we have made in response to patient feedback or complaints (interview).
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status quo of quo vadis? - KCE

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