Providing good care

Patient care is the practitioner's primary concern in clinical practice. Good care means the practitioner: (a) assesses the patient using their history (covering relevant psychological, social and cultural matters, and electronic records on hand such as My Health Record), their views and a suitable physical examination where relevant; (b) formulates, records and carries out a suitable management plan, including treatment, advice, investigations and liaison with other treating practitioners; (c) facilitates coordination and continuity of care; (d) recognises where their skills and competence end and stays inside that boundary and refers when that is in the patient's best interests; (e) recognises healthcare decisions as shared between practitioner and patient, who may involve family, carers or others; and (f) respects patients' right to make their own decisions about current and future care.

• Sampled patient records showing a documented history covering psychological, social and cultural factors and a recorded examination where relevant
• Written management plans in the record with treatment, advice, investigations ordered and liaison with other treating practitioners
• Referral letters showing onward referral where a case exceeded the practitioner's competence
• Notes recording shared decision-making and the patient's stated choices

• Records hold treatment entries but no assessment or plan
• No referral where the presentation was outside the practitioner's scope
• Patient's own decisions and preferences never recorded