Standards in medical 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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Medical Record Keeping in the Summer Camp Setting.

BACKGROUND Approximately one fifth of school-aged children spend a significant portion of their year at residential summer camp, and a growing number have chronic medical conditions. Camp health records are essential for safe, efficient care and for transitions between camp and home providers, yet little research exists regarding these systems. OBJECTIVE To survey residential summer camps for...

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The CRABEL score--setting standards in maxillofacial medical note-keeping.

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ژورنال

عنوان ژورنال: Clinical Medicine

سال: 2003

ISSN: 1470-2118,1473-4893

DOI: 10.7861/clinmedicine.3-4-329