Medical Records

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. Unless everyone involved in clinical management has access to the information they require, duplication of work, delays and mistakes are inevitable.

Records may be held electronically or manually, or a mixture of both. Some health 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 whilst most hospitals hold basic data on an electronic patient record linked by identification numbers to the main, usually paper-based, hospital record cross-referencing to other files that may exist, for example in the A&E or physiotherapy departments.