Patient Registration & Continuity of Care
Patient Registration & Continuity of Care
MANDATORY
5 criteria
| Standard 1.1 NON-NEGOTIABLE · Standard 1: Patient Registration & Continuity of Care Every Patient Is Empaneled to a Specific, Named Clinician |
ASSESSMENT ASF-PHC-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 1.1 NON-NEGOTIABLE L1 |
THE STANDARD Every Patient Is Empaneled to a Specific, Named Clinician Every registered patient is formally empaneled — assigned to a specific, named clinician or care team responsible for their ongoing care — not simply added to a general patient list with no defined, accountable relationship. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is every registered patient formally empaneled to a specific, named clinician or care team? A real, specific assignment, not a general patient list with no defined accountability. Doc: Empanelment record |
YES | PARTIAL | NO |
| 2 | Is empanelment genuinely sensitive to patient and family preference, not assigned arbitrarily? Genuine consideration of preference, not a mechanical assignment process alone. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Can a patient or staff member identify exactly who this patient's primary clinician is, without ambiguity? A clear, unambiguous answer, not uncertainty about who is actually responsible. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Empanelment record review |
Reviews records for a sample of patients to confirm genuine, specific empanelment. |
| ASK Preference sensitivity interview |
Asks staff how empanelment accounts for patient and family preference. |
| ASK Clinician identification check |
Asks a patient or staff member to identify a specific patient's assigned clinician. |
REFERENCES
- [1] Empanelment is the act of assigning individual patients to individual primary care providers and care teams with sensitivity to patient and family preference, and is established as the basis for population health management and therapeutic continuity in primary care practice.
| Standard 1.1 · Standard 1: Patient Registration & Continuity of Care Guidance & Learning |
GUIDANCE ASF-PHC-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
Empanelment is the actual mechanism that makes primary care primary care — without a specific clinician genuinely accountable for a patient's ongoing health, care fragments into a series of disconnected encounters with whoever happens to be available, losing exactly the continuity that gives primary care its real value.
| WHAT GOOD LOOKS LIKE ✓ Every patient is genuinely, specifically empaneled to a named clinician or team. ✓ Empanelment genuinely considers patient and family preference. ✓ Anyone can clearly identify a patient's assigned clinician without ambiguity. |
WHAT FAILURE LOOKS LIKE ✗ Patients are added to a general list with no specific, accountable assignment. ✗ Empanelment is mechanical, with no genuine consideration of preference. ✗ Staff or patients are uncertain who is actually responsible for a patient's care. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 Empanelment happens for most patients but new registrations sometimes wait before formal assignment.
The protective value of empanelment applies from the first visit, not after an administrative delay.
2 Assignment is specific but doesn't account for a patient's stated preference for a particular clinician.
Genuine sensitivity to preference is part of what makes the relationship therapeutic, not just administrative.
3 Empanelment records exist but aren't consistently updated when a clinician leaves the practice.
A patient's empanelment needs to reflect who is actually currently responsible for their care.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current registration practice for genuine, specific empanelment versus general list addition.
Week 2 Establish a formal empanelment process considering patient and family preference.
Week 3 Build a clear, accessible record of each patient's current empaneled clinician.
Ongoing Update empanelment promptly when clinician staffing changes.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a random patient in the waiting room who their assigned doctor is.
A confident, specific answer reveals genuine empanelment, not assumed continuity.
Ask what happens to empanelment when a clinician leaves the practice.
A specific, confident answer reveals a genuine, maintained process, not one that quietly goes stale.
| E-LEARNING academy.gmj.ge/phc-std1-1-empanelment — 30 min · complete before self-assessment |
| Standard 1.2 NON-NEGOTIABLE · Standard 1: Patient Registration & Continuity of Care A Patient's Own Medical History Is Actually Known and Used, Not Treated as a New Encounter Each Visit |
ASSESSMENT ASF-PHC-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 1.2 NON-NEGOTIABLE L1 |
THE STANDARD A Patient's Own Medical History Is Actually Known and Used, Not Treated as a New Encounter Each Visit A patient's relevant medical history, prior visits, and ongoing issues are genuinely reviewed and actively used at each visit — not treated as a fresh encounter each time, with the clinician relying only on what the patient happens to mention that day. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Is a patient's relevant history genuinely reviewed before or during each visit, not relied on solely from what they mention that day? Real, active review of the actual record, not passive reliance on patient recall alone. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 2 | Are ongoing issues from prior visits actively followed up, not lost between encounters? Genuine, tracked follow-through, not issues that quietly drop between visits. Doc: Ongoing issue tracking record |
YES | PARTIAL | NO |
| 3 | Can the clinician describe specific, relevant history for a patient without the patient having to repeat it? Genuine, demonstrated knowledge, not dependence on the patient re-explaining their own history each time. Doc: N/A — tested directly |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| OBSERVE History review observation |
Observes an actual visit for genuine review and use of the patient's existing history. |
| DOCUMENT Follow-up tracking review |
Reviews whether ongoing issues from prior visits are tracked and genuinely followed up. |
| ASK Patient experience interview |
Asks a patient whether they feel they have to re-explain their history at each visit. |
REFERENCES
- [2] Retrospective analysis of linked health administrative data found continuity of care with an individual family physician is associated with reduced emergency department visits and hospitalizations across varying levels of patient complexity, establishing relational continuity as a mechanism with genuine, measurable clinical benefit.
| Standard 1.2 · Standard 1: Patient Registration & Continuity of Care Guidance & Learning |
GUIDANCE ASF-PHC-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
Relational continuity — a genuine, ongoing relationship where the clinician actually knows the patient's history — is the core, evidence-based mechanism through which primary care improves outcomes, and a practice that doesn't genuinely use this history at each visit provides none of continuity's real, documented benefit, regardless of whether the same clinician is technically assigned.
| WHAT GOOD LOOKS LIKE ✓ History is genuinely reviewed and actively used at each visit. ✓ Ongoing issues are actively tracked and followed up, not lost between visits. ✓ Patients don't have to repeatedly re-explain their own history. |
WHAT FAILURE LOOKS LIKE ✗ Each visit is treated as a fresh encounter, relying on what the patient mentions that day. ✗ Ongoing issues from prior visits are lost or not followed up. ✗ Patients regularly find themselves re-explaining history the practice should already know. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 History review happens for complex, chronic patients but less consistently for those with simpler needs.
Every patient benefits from genuine continuity, not only those with the most complex conditions.
2 Review happens when the same clinician sees the patient but less reliably when a covering clinician is involved.
Continuity of information should hold even when the usual clinician isn't the one seeing the patient that day.
3 Follow-up tracking exists but isn't consistently checked before the next relevant visit.
A tracking system that isn't actively checked provides limited real protective value.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current practice for genuine history review versus fresh-encounter treatment.
Week 2 Establish a standard pre-visit history review step for every patient, including with covering clinicians.
Week 3 Build an active ongoing-issue tracking and follow-up process.
Ongoing Audit whether tracked issues are genuinely being followed up.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a patient whether they feel their doctor genuinely remembers their history.
This tests lived experience of continuity, not administrative record-keeping alone.
Observe a visit with a covering clinician specifically.
This is where genuine use of existing history is most likely to lapse.
| E-LEARNING academy.gmj.ge/phc-std1-2-history-continuity — 30 min · complete before self-assessment |
| Standard 1.3 CORE · Standard 1: Patient Registration & Continuity of Care Continuity Is Actively Measured, Not Assumed |
ASSESSMENT ASF-PHC-STD1-v3.0 |
| CR N/A | TR FULL | SM ADAPTED | ST FULL |
| 1.3 CORE L1 |
THE STANDARD Continuity Is Actively Measured, Not Assumed The practice actively measures its own continuity of care — the proportion of a patient's visits that are genuinely with their own empaneled clinician or team — not assuming continuity is adequate without ever actually checking. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does the practice actively calculate a real continuity measure, not assume continuity is adequate? A genuine, calculated measure, not an unverified assumption. Doc: Continuity measurement record |
YES | PARTIAL | NO |
| 2 | Is this measure reviewed regularly, not calculated once and forgotten? Genuine, ongoing review, not a one-time calculation. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | When continuity is found to be low for a specific patient or pattern, is there a genuine response? Real, active response to a low result, not a measure tracked without consequence. Doc: Low-continuity response record |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Continuity measurement review |
Reviews whether the practice genuinely calculates a real continuity metric. |
| DOCUMENT Review frequency check |
Reviews how regularly the continuity measure is actually reviewed. |
| ASK Low-continuity response interview |
Asks staff what happens when continuity is found to be low for a specific pattern or patient. |
REFERENCES
- [3] The Usual Provider of Care Index, defined as the proportion of a patient's visits with their own designated primary care provider, is an established, validated metric for measuring genuine continuity of care in primary care practice.
| Standard 1.3 · Standard 1: Patient Registration & Continuity of Care Guidance & Learning |
GUIDANCE ASF-PHC-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
A practice that doesn't measure its own continuity has no real way of knowing whether the relational continuity it depends on for better outcomes is actually happening in practice, or has quietly eroded as scheduling pressures and staff changes accumulate over time.
| WHAT GOOD LOOKS LIKE ✓ A genuine continuity measure is actively calculated, not assumed. ✓ The measure is reviewed regularly, not calculated once and forgotten. ✓ Low continuity triggers a genuine, active response. |
WHAT FAILURE LOOKS LIKE ✗ No real continuity measure exists; adequacy is simply assumed. ✗ A measure exists but is calculated once and never revisited. ✗ Low continuity, if identified, produces no real response. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 A continuity measure exists but is calculated for the practice as a whole, not for individual clinicians.
Practice-wide averages can mask genuine variation that matters for specific patients or clinicians.
2 Review happens periodically but isn't tied to any specific threshold that would trigger action.
A measure without a genuine action threshold provides limited real value for improvement.
3 Low continuity is identified for specific patients but a systemic pattern across the practice isn't reviewed collectively.
Individual cases and systemic patterns each deserve genuine attention.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current practice for genuine continuity measurement versus assumed adequacy.
Week 2 Establish a real, calculated continuity measure at both individual and practice level.
Week 3 Define a specific threshold that triggers genuine review and action.
Ongoing Review continuity measures regularly and act on identified patterns.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask to see the practice's actual, calculated continuity figure, not a general impression.
A specific, real number reveals genuine measurement, not an assumption.
Ask what happened the last time continuity was found to be low for a specific pattern.
A real example reveals whether measurement leads to genuine action.
| E-LEARNING academy.gmj.ge/phc-std1-3-continuity-measurement — 30 min · complete before self-assessment |
| Standard 1.4 CORE · Standard 1: Patient Registration & Continuity of Care Registration Captures What Actually Matters for Ongoing Care |
ASSESSMENT ASF-PHC-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 1.4 CORE L1 |
THE STANDARD Registration Captures What Actually Matters for Ongoing Care Patient registration captures genuinely relevant information for ongoing primary care — chronic conditions, family history, social context affecting health — not only administrative and billing information, treated as sufficient on its own. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does registration genuinely capture chronic conditions, family history, and relevant social context, not only administrative details? Real, clinically relevant information, not billing and contact details alone. Doc: Registration content documentation |
YES | PARTIAL | NO |
| 2 | Is this information actively used to inform the patient's early care, not collected and left unused? Genuine, early use of registration information, not documentation without follow-through. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | Is registration information genuinely updated over time, not treated as fixed from the first visit? Real, ongoing updates, not information that grows stale as the patient's circumstances change. Doc: Registration update record |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Requires improvement plan.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Registration content review |
Reviews registration records for genuine clinical and social content, not administrative information alone. |
| OBSERVE Early use observation |
Observes whether registration information genuinely informs a patient's early care. |
| DOCUMENT Update record review |
Reviews whether registration information is genuinely updated over time. |
REFERENCES
- [4] Comprehensive intake capturing chronic conditions, family history, and social context, distinct from administrative registration alone, is established practice in primary care literature as foundational to effective population health management and individualized care.
| Standard 1.4 · Standard 1: Patient Registration & Continuity of Care Guidance & Learning |
GUIDANCE ASF-PHC-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
Registration is the foundation the entire ongoing relationship builds on, and a registration process focused only on administrative necessity misses information that genuinely shapes what good primary care looks like for this specific patient from the very first visit.
| WHAT GOOD LOOKS LIKE ✓ Registration genuinely captures relevant clinical and social information, not administrative details alone. ✓ This information actively informs the patient's early care. ✓ Registration information is genuinely updated as circumstances change. |
WHAT FAILURE LOOKS LIKE ✗ Registration focuses only on administrative and billing information. ✗ Collected information isn't used to inform actual early care. ✗ Registration information remains static from the first visit onward. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 Chronic conditions are captured well but family history is inconsistently collected.
Family history carries real, genuine relevance for preventive care planning.
2 Social context is asked about but not consistently connected to actual care planning.
Information that doesn't inform care provides limited real value beyond documentation.
3 Registration is thorough at the first visit but rarely revisited as a patient's life circumstances change.
A patient's relevant social and family context can genuinely change over the course of an ongoing relationship.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current registration content for genuine clinical and social relevance.
Week 2 Build a structured intake capturing chronic conditions, family history, and social context.
Week 3 Establish a process connecting registration information to early care planning.
Ongoing Revisit and update registration information periodically.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask to see a specific patient's registration record for genuine clinical and social content.
A real, specific record reveals whether this is genuine practice, not administrative intake alone.
Ask how registration information from a patient's first visit informed their actual early care.
A specific, real example reveals genuine use, not documentation for its own sake.
| E-LEARNING academy.gmj.ge/phc-std1-4-registration-content — 30 min · complete before self-assessment |
| Standard 1.5 NON-NEGOTIABLE · Standard 1: Patient Registration & Continuity of Care A Patient Can Reach Their Own Clinician or Care Team, Not Just Whoever Is Available |
ASSESSMENT ASF-PHC-STD1-v3.0 |
| CR ADAPTED | TR FULL | SM FULL | ST FULL |
| 1.5 NON-NEGOTIABLE L1 |
THE STANDARD A Patient Can Reach Their Own Clinician or Care Team, Not Just Whoever Is Available A patient has a genuine, defined way to reach their own empaneled clinician or care team for an ongoing issue — not only the option of whoever happens to be available that day, with no real path back to the clinician who actually knows their history. |
| CLINIC SELF-ASSESSMENT Tick YES, PARTIAL, or NO for each question. |
| 1 | Does a patient have a genuine, defined way to reach their own empaneled clinician or team? A real, specific pathway, not default routing to whoever is available. Doc: Patient contact pathway documentation |
YES | PARTIAL | NO |
| 2 | Is this pathway genuinely known to patients, not just theoretically available? Real, communicated awareness, not an option patients don't know exists. Doc: N/A — tested directly |
YES | PARTIAL | NO |
| 3 | When the patient's own clinician genuinely isn't available, is there a defined handoff that preserves relevant history? A real, structured handoff, not a complete loss of continuity when the usual clinician is out. Doc: Coverage handoff protocol |
YES | PARTIAL | NO |
ALL YES Standard likely met. ANY PARTIAL Improvement plan required. ANY NO Blocks accreditation until resolved.
| WHAT THE ASSESSOR DOES ON SITE no surprises, no hidden checks |
| DOCUMENT Contact pathway review |
Reviews the actual, defined pathway for patients to reach their own clinician or team. |
| ASK Patient awareness interview |
Asks a patient whether they know how to reach their own assigned clinician. |
| DOCUMENT Coverage handoff review |
Reviews the structured handoff process when the patient's own clinician is unavailable. |
REFERENCES
- [5] A genuine, defined pathway for patients to reach their own assigned clinician or care team, distinct from default routing to any available provider, is established practice for preserving the real value of primary care continuity.
| Standard 1.5 · Standard 1: Patient Registration & Continuity of Care Guidance & Learning |
GUIDANCE ASF-PHC-STD1-v3.0 |
| WHY THIS STANDARD EXISTS |
Empanelment only delivers its real value if a patient can genuinely reach the clinician they're actually assigned to when it matters — a system where every contact defaults to whoever is available undermines the entire continuity relationship this standard exists to protect.
| WHAT GOOD LOOKS LIKE ✓ A genuine, defined pathway lets patients reach their own clinician or team. ✓ Patients are genuinely aware this pathway exists. ✓ A structured handoff preserves relevant history when the usual clinician is unavailable. |
WHAT FAILURE LOOKS LIKE ✗ Patients default to whoever is available, with no real path to their own clinician. ✗ Patients are unaware any specific pathway to their own clinician exists. ✗ No structured handoff exists, and continuity is lost when the usual clinician is out. |
| MOST COMMON REASONS CLINICS SCORE PARTIAL |
1 A pathway exists for scheduled appointments but not for urgent same-day needs.
Continuity matters as much, if not more, in urgent moments as in scheduled ones.
2 Patients are told about the pathway once at registration but it isn't reinforced over time.
A pathway mentioned once, long ago, is easily forgotten by the time a patient actually needs it.
3 Coverage handoff happens but relevant history isn't consistently communicated to the covering clinician.
A handoff without genuine information transfer doesn't preserve the real value of continuity.
| HOW TO IMPLEMENT IF YOU ARE STARTING FROM ZERO |
Week 1 Review current patient contact pathways for genuine access to their own clinician.
Week 2 Establish a clear, communicated pathway for both scheduled and urgent contact.
Week 3 Build a structured coverage handoff process preserving relevant patient history.
Ongoing Reinforce pathway awareness with patients periodically, not only at initial registration.
| FOR SURVEYORS — WHAT IS NOT OBVIOUS |
Ask a patient directly how they would reach their own doctor for an urgent concern.
A confident, specific answer reveals a genuine, known pathway, not an assumed one.
Ask what information a covering clinician actually receives when the usual clinician is unavailable.
A specific, real answer reveals whether handoff genuinely preserves continuity.
| E-LEARNING academy.gmj.ge/phc-std1-5-clinician-access — 30 min · complete before self-assessment |
Primary Health Clinic Standards — overviewFacility Classification — Which Type of Facility Are You?Standard 1 — Patient Registration & Continuity of CareStandard 2 — Preventive Care & ScreeningStandard 3 — Chronic Disease ManagementStandard 4 — Acute & Same-Day CareStandard 5 — Referral & Care CoordinationStandard 6 — Clinical Environment & SafetyStandard 7 — Governance & StaffingStandard 8 — Health & MigrationReferences & Index
STANDARD 1Patient Registration & Continuity of Care1.1 Every Patient Is Empaneled to a Specific, Named Clinician1.3 Continuity Is Actively Measured, Not Assumed1.4 Registration Captures What Actually Matters for Ongoing Care1.5 A Patient Can Reach Their Own Clinician or Care Team, Not Just Whoever Is Available
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