Letter: On immunization record keeping.

Record keeping chart…

Record keeping: developing good practice

THE LAST decade has seen a shift of attitude within the nursing profession towards the importance of record keeping. This change has been brought about predominantly by the promotion of patients’ rights and the empowerment of patients and relatives to be involved in their care, through the Patient’s Charter (DoH 1991). This has now been superseded by Patient Focus and Public Involvement (Scotti...

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...

Letter to Editor: Keeping the Dialogue Going.

Journals publish a variety of manuscripts under the section titled "Letters to the Editor". This communication discusses the important role played by letters written as a comment on an article previously published in the journal and provides suggestions regarding the way to write such letters.

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...