Australia RACGP Standards for General Practices (5th edition) C6.2: Patient health record systems: the practice has a system for managing patient health information and, if it runs a hybrid paper and electronic system, records every consultation or interaction in each system with a note of where the clinical notes are kept

What does C6.2 require?

Health information has to be findable and complete. The practice chooses and maintains a record system, usually clinical software, with controls over who can create, read and change records, regular backups and a procedure for scanning or filing correspondence and results. Where both paper and electronic records are in use, every consultation or interaction is noted in both and each record says where the clinical notes for that encounter live, so no clinician works from a partial picture. The practice plans to move to a single electronic record where it still relies on paper.