Patient data can sometimes be difficult to compile, manage and share in an accurate and clear manner. Even so, maintaining medical records in such a way are not only essential for continuous patient care, but they are also a code of conduct for Australian doctors under the Medical Board of Australia.
This raises the question of how to provide the best workflow that captures meaningful data without imposing an administrative burden. Without the right tools, this can be a hassle for not only GPs, but medical practices themselves.
Collecting accurate patient data
In order to promote continuity of care, GPs and practice owners should be using technology that allows them to keep patient records accurate and up to date. By using consistent formatting and relevant fields, GPs can capture and share meaningful data that includes:
- Clinical history
- Clinical findings
- Patient management guidelines
- Medication and other management
Accurate patient data isn’t only about how data is compiled, but also about how it can be managed and shared with both other healthcare professionals and the patients themselves. The use of standardised terminology helps everyone in a patient’s care cycle provide the best quality care.
Continuous patient care not only includes accurate compiling of patient data, but also ensuring the way the data is captured is relevant to all patients and situations.
In 2016, the Australian Bureau of Statistics (ABS) released the Standard for Sex and Gender Variables. The sex variable is defined as the ‘biological characteristics’ of a person’s body’ with the gender variable being defined as ‘the way a person feels, presents and is recognised within the general community.’
Collecting, reporting and using patient data should be standardised and consistent in all aspects of a patient’s medical record as to ensure the provision of high quality care.