Improving standards in clinical record-keeping

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Standards in medical record keeping.

Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation a...

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Medical records and record-keeping standards.

The structure of medical records becomes ever more critical with the advent of electronic records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Records Standards programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Lab...

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Service standards: chaperones and record keeping.

Journal of Family Planning and Reproductive Health Care 2004: 30(4) Canadian study reviewed the success of a pilot programme for providing EC via a pharmacy without a prescription.4 Almost 7000 prescriptions were obtained and 21% of women stated that if they had not obtained EC in this manner, they would not have obtained it elsewhere. The Canadian health minister recently introduced a bill to ...

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Improving nurse documentation and record keeping in stoma care.

Evidence suggests that nurse documentation is often inconsistent and lacks a coherent and standardized approach. This article reports on research into the use of nurse documentation on a stoma care ward in a large London hospital, and explores the factors that may affect the process of record keeping by nursing staff. This study uses stoma care as a case study to explore the role of documentati...

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clinical audits and the state of record keeping in india

There is no legislative framework in In-dia at the moment, which would enable collating data from hospitals on standard indicators of quality of patient care. It is only such data on patient care processes and outcomes, which would enable any meaningful audit of medical services with a view to making these services patient oriented. Hospital services should be such as to facilitate better patie...

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ژورنال

عنوان ژورنال: Advances in Psychiatric Treatment

سال: 2006

ISSN: 1355-5146,1472-1481

DOI: 10.1192/apt.12.4.280