Practices rarely fail accreditation because the systems are missing. They fail because they cannot show the evidence on the day. This guide walks how to build an evidence pack that maps cleanly to the Standards, so a surveyor can follow your proof indicator by indicator. It runs alongside the self-assessment guide: the self-assessment tells you where you stand, the pack is where the evidence lives. For the wider accreditation picture, see the RACGP accreditation pillar.
Before you begin
You need your current indicator list and the result of a self-assessment (even a rough one), because the pack is built around the indicators, not around your filing system. Decide where the pack will live (a structured folder, shared drive, or your compliance platform) and who owns keeping it current. If you are new to the process, the getting started with RACGP accreditation post sets the context.
Step 1: Map each indicator to the evidence it needs
Start with the indicator, then ask what would prove it. For each one, list the evidence a surveyor would expect: usually a policy that shows the system exists, plus the records that show it runs. Give mandatory indicators the closest attention, because a failed mandatory indicator stops accreditation regardless of how good the rest of the pack is.
This mapping is the backbone of the whole pack. Working indicator by indicator, rather than gathering documents you happen to have, is what guarantees you collect what is actually assessed instead of what is easy to find.
Step 2: Gather the policy and the running records for each
For every indicator, pull together both halves of the proof: the document that describes the system and the records that show it operating (training logs, fridge temperature logs, audit results, complaint records, meeting minutes). One without the other is a half-answer; a policy with no records reads as aspirational, and records with no policy read as ad hoc.
Collect the real, current artefacts, not idealised versions. The point of the pack is to reflect what your practice genuinely does, so a surveyor's spot check matches what you have filed.
Step 3: Fill the gaps and flag evidence that needs time
Compare what each indicator needs against what you have, and write down the gaps. Some you can close immediately by writing the missing policy or starting the missing log. Others, like a quarter of temperature logs or a completed quality-improvement cycle, cannot be created retrospectively and only accumulate over time.
Flag those time-dependent gaps first, because they set your real timeline. The common accreditation failures are worth checking your list against here, since the same evidence gaps recur across thousands of practices and are predictable to pre-empt.
Step 4: Organise the pack so an assessor can follow it
Structure the pack to mirror the Standards, so each indicator points to its evidence in one move. Label everything clearly, keep current versions only (archive superseded documents elsewhere), and add a simple index that maps indicator to evidence location. A surveyor who can find your proof quickly forms a very different impression from one who watches you hunt for it.
Good organisation is itself a signal of a well-run practice. The pack should read as a system someone maintains, not a pile assembled the week before the survey.
Step 5: Keep the pack living between cycles
Treat the pack as a standing system, not a survey-week project. As policies are reviewed and records accumulate, file them into the pack as you go, so it is always close to survey-ready. This is where the evidence pack becomes part of continuous quality improvement: the same records that prove an indicator also feed your improvement cycles.
A maintained pack turns each accreditation cycle from a scramble into a review. The work is spread across the cycle instead of compressed into the weeks before survey day.
What good looks like
- Every indicator maps to specific, locatable evidence, mandatory indicators first.
- Each indicator has both a policy and the records that show it runs.
- Time-dependent evidence was identified early and given runway to build.
- The pack is structured to mirror the Standards, with a clear index.
- It is maintained continuously, not assembled the week before survey.
Common mistakes: collecting documents you have rather than evidence each indicator needs, providing policies with no supporting records, leaving evidence-over-time items until they cannot be built, and rebuilding the pack from scratch every cycle.
Frequently asked questions
What goes in an accreditation evidence pack?
For each indicator, the policy or document that shows the system exists, plus the records that show it runs (training logs, temperature logs, audit results, complaint records, meeting minutes). The pack is organised by indicator so a surveyor can match each requirement to its proof.
How far in advance should I start building the pack?
Start roughly 12 months before your survey, because some evidence (completed quality-improvement cycles, a full run of routine logs) only accumulates over time and cannot be created retrospectively. The documents can be written quickly; the running records are what need runway.
What is the difference between a self-assessment and an evidence pack?
A self-assessment rates how well you meet each indicator; the evidence pack is where the proof for each indicator is gathered and organised. They are the same workflow viewed two ways, which is why you build the pack as you run the self-assessment.
Do I need evidence for every indicator?
Yes. Each indicator must be demonstrated, and a failed mandatory indicator stops accreditation. The pack exists so that every indicator, especially the mandatory ones, points to evidence a surveyor can review without delay.
Can software build the evidence pack for me?
A compliance platform helps by storing policies and records against the indicators and flagging gaps, but the evidence still has to be real: the systems must actually run and generate the records. The tool organises and surfaces the proof; it does not manufacture it.
Part of
RACGP AccreditationLast reviewed