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Medical Records in Ireland: An MPS Guide

Correct as of September 2013. The right of Sandy Anthony to be identified as the author of the text of this work has been asserted by her in accordance with Copyright, Designs and Patents Act 1988.

Introduction

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.

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The information contained in clinical records may also be required for a range of non-clinical uses described later in this booklet. 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.