AS 2828.1:2019 PDF

AS 2828.1:2019 PDF

This Standard specifies requirements for the physical aspects of paper health records, including size, quality, reproducibility, layout, colour, division, methods of fixing, and cover. This Standard also provides advice on design of forms for incorporation into health records. This Standard does not address specific record content in terms of the quality of clinical documentation requirements.

This Standard represents an update of requirements first published in AS 2828—1985, Hospital medical records and supports the key role of paper health records in recording details of the care given to subjects of care (individual/patients) by a healthcare provider and for storing other relevant information relating to a subject of care. Part 2 in the series addresses the specific requirements for digitized health records. Requirements for health records stored as electronic health records have yet to be addressed.

Good quality health records enhance the quality and continuity of health care by —

(a) facilitating communication, especially between healthcare providers;

(b) providing evidence of care provision; and

(c) providing an efficient source of knowledge acquisition and exchange.

This Standard seeks to capture the benefits of standardizing the identification, physical characteristics and organization of paper health records while recognizing the needs of a wide range of healthcare providers operating within different jurisdictions.