Australia RACGP Standards for General Practices (5th edition) C7.1: Content of patient health records: each patient has one record holding all the practice's health information about them; active records contain identification, contact, demographic, next of kin and emergency contact details, consultation notes and clinical communications, evidence that earlier issues were followed up, Aboriginal and Torres Strait Islander status, cultural background where relevant, and lifestyle risk factors

What does C7.1 require?

A complete record is the foundation of continuity. The practice keeps a single record for each patient containing all the health information it holds about them. For each active patient (seen three or more times in two years) the record includes their identification and contact details, demographic information, next of kin and emergency contact, notes of each consultation and clinically related communication such as phone advice and results discussions, and evidence that matters raised previously have been followed up. The record routinely captures whether the patient identifies as Aboriginal or Torres Strait Islander, their cultural background where relevant to care, and lifestyle risk factors such as smoking, alcohol, nutrition, physical activity and weight.