82996 - Patient Health Summary - Medical Director
- : Online
This module explains how accurate and up to date health summaries contribute to the quality of care provided to patients, and how to efficiently enter patient health information into the clinical software.
Relevance to General Practice
A complete health summary assists the patient’s GP and other health care providers the patient may be referred to. Up to date health summaries reduce the risk of inappropriate patient management and need to be developed on a progressive basis.
Recording health summary information in the correct section of the software using clinical coding allows the information to be accessed readily by other health professionals within the practice and reduces the risk of inappropriate management of patients’ health.
The Medical Board of Australia, Codes, Guidelines and Policies, section 8.4 Medical Records, state; the maintenance of clear and accurate medical records are essential for the continuing good care of patients (1).
The goal of this activity is to provide the skills required to accurately and efficiently record health summaries enabling the provision of high quality patient care.
References: 1. https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
- Accurately and efficiently record health summary information using clinical software
- Refer to industry guidelines when recording health summaries in patient health records
- Refer to industry standards to determine active patient health records