Australia RACGP Standards for General Practices (5th edition) QI1.3: Improving clinical care: the team codes clinical information with a nationally recognised medical vocabulary, and the practice uses its patient and practice data to improve clinical care, for example in chronic disease management and preventive health

What does QI1.3 require?

Data only helps when it is coded consistently. Clinicians record diagnoses, reasons for visit and other key information using the coded terms in the clinical software, which draw on a nationally recognised vocabulary such as DOCLE, ICPC or SNOMED CT, rather than free text alone, so that searches and audits are reliable. The practice then interrogates its data, with clinical audit tools or built-in reports, to find gaps such as diabetic patients overdue for review, unrecorded smoking status or missed screening, and runs improvement activities to close them.