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 This has now been superseded by Patient Focus and Public Involvement (Scotti...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...

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...

Record keeping in two types of relationships.

On the basis of a distinction between communal and exchange relationships (Clark & Mills, 1979; Mills & Clark, 1982), the following predictions were made: (a) Members of exchange relationships would keep track of individual inputs into joint tasks and (b) members of communal relationships would not. These hypotheses were tested in three studies. In each study, subjects worked on a task with a p...