Collecting cultural identity information and quality patient health records

The collection of cultural identity information is mandatory for practices undergoing accreditation. RACGP Standards (Criterion1.4.1D, 1.7.1D, and 2.1.1G). Practices should be working towards capturing this information.

Practices need to be working towards the routine recording of patients’ cultural backgrounds, including self-identified Aboriginal and/or Torres Strait Islander status in order to assist in appropriately tailoring care. Aboriginal and/or Torres Strait Islander self-identification refers to the process by which patients are encouraged to identify themselves as being of Aboriginal and/or Torres Strait Islander origin. When this information is reported and recorded in health information systems the resulting data item is known as the patient’s ‘self-identified Aboriginal and Torres Strait Islander Status’.

Collecting information from patients

It is important to encourage patients to self-identify as Aboriginal and/or Torres Strait Islander. The standard Indigenous status question is, ‘Are you of Aboriginal and/ or Torres Strait Islander origin?’ This question should be asked of all patients, irrespective of appearance, country of birth or whether the staff know of the patient or their family background.

Sometimes practice teams feel concerned that obtaining Aboriginal and Torres Strait Islander status can be perceived as discriminatory. However, the information is very important because of the different health needs of Aboriginal and Torres Strait Islander people.

Practices should be working towards recording the following information in their active patient health records and it is no longer up to the patient to just self-identify. Practices need to actively ask the question of all patients and demonstrate evidence of this being recorded in the patient’s health record.

There are many ways the practice team can work towards ensuring all health records are up to date and appropriate cultural identification takes place.

  • Cultural awareness training. (Central and Eastern Sydney PHN can offer this training)
  • Staff meetings.
  • Development of a patient questionnaire that patients can complete while waiting for their appointment. The patient can hand the questionnaire directly to the doctor/ practice nurse for their health records to be updated.
  • Practice information sheet encouraging patients to identify their cultural background and/ or ethnicity.
  • Health promotion material directly relevant to Indigenous patients such as posters in the waiting room or brochures. (All available from CESPHN).
  • Information on your TV, website or Aboriginal art displayed in your waiting room.

As your practice prepares for accreditation or reaccreditation the benefits of culturally identifying patients and quality health records not only ensures that patients receive better health outcomes and a more informed understanding of closing the Gap Initiatives but it is also rewarding financially for practices, enabling them to access the Indigenous PIP.