Medical Records

Good clinical records are a prerequisite of delivering high-quality, evidence-based healthcare, particularly where a number of different clinicians are contributing simultaneously to patient care. Everyone involved in a patient’s clinical management
should have access to the information they need – otherwise, duplication of work, delays and mistakes are inevitable.

Records may be held electronically or manually, or a mixture of both. Some healthcare professionals – for example physiotherapists, occupational therapists, speech therapists and psychologists – often maintain separate departmental records, sometimes (but not always) copying important information relevant to others into the main hospital record. But in any event, a patient’s clinical record is never a single document.

Increasingly, GPs hold their records in computerised form and many hospitals hold a mixture of electronic and paper records.

These should be cross-referenced with other files that may exist in various departments. The information contained in clinical records may also be required for a range of non-clinical uses described below. Clinical records contain sensitive personal data, and keeping them secure from prying eyes or inadvertent disclosure is a legal – as well as a professional – responsibility.