What are clinical records?
Clinical records include a wide variety of documents generated on, or on behalf of, all the health grofessionals involved in patient care. This includes:
- Handwritten clinical notes
- Computerised/electronic clinical records
- All personal correspondence (including letters, faxes, text messages and emails) relating to clinical matters, including correspondence sent between hospital and practice
- Scanned records
- Laboratory results
- X-ray films and other imaging records
- Photographs
- Videos and audio recordings
- Printouts from monitoring equipment, particularly in anaesthesia and obstetrics, A&E and ICU
- Consent forms.
Clinical records include a wide variety of documents generated on, or on behalf of, all the health grofessionals involved in patient care