Paper health records no longer acceptable in general practice

These are just some of the changes in the sixth edition of the RACGP Standards for general practice – the benchmark for quality and safety in general practice.

The College said this edition represents the latest evolution of general practice and builds on established principles to support GPs to meet the expectations of patients.

Six new and updated topics are covered, including defining and planning for your practice, environmental sustainability, artificial intelligence, reprocessing, engaging consumers and continuous quality improvement.

Among the clinical governance changes that GPs need to be aware of is a move away from paper-based health records.

“Paper health records are no longer acceptable. Practices must use a digital clinical information system to manage patient health information,” information on the RACGP website states.

It acknowledges that hybrid solutions may be required for patients in aged care facilities, but all systems in general practice must be digital.

In an expansion to the fifth edition of the standards, all patient health records must now include known allergies or a record of no known allergies, and demographic identification details.

Managing clinical risks

All practices are now required to have a clinical risk management system in place that identifies, monitors, mitigates and evaluates clinical risks in the practice.

The practice will be expected to have a documented process for clinical risk management in place, maintain a clear clinical risk register, and develop procedures to mitigate these risks.

The standards state the register could be as simple as a table or spreadsheet that tracks the level of each clinical risk.

It suggests that practices could schedule regular risk management meetings and foster a culture of open communication to stay on top of and mitigate future risks.

Chair of the RACGP Expert Committee Standards for General Practice Dr Louise said the standards were informed by extensive consultation with GPs, practice teams, and sector stakeholders, alongside consumer engagement, evidence reviews, and pilot testing.

“Digital transformation, changing patient expectations, and the health impacts of climate change are among the issues shaping the future landscape,” she said.

“The standards reinforce the role of accreditation not simply as a regulatory requirement, but as a driver of quality improvement, professional integrity and public trust.”

President Dr Michael Wright shared decision-making and patient-centred care are core to good general practice.

“The standards aim to support practices as they adapt to modern consumer expectations, consider how AI can improve care, implement environmental sustainability, and thrive in an often-challenging financial environment,” he said.

“They’re also strongly outcomes-focused, and don’t prescribe rigid processes. They provide flexibility for practices to implement systems that suit their circumstances, while meeting the expectations of our patients for high-quality care that’s tailored to their needs.

“Whether your practice is already accredited or considering accreditation, the standards will support and guide you and your team.”