Standards in medical record keeping

被引:81
作者
Mann, R
Williams, J
机构
[1] Royal Coll Physicians, Hlth Informat Unit, London NW1 4LE, England
[2] Univ Coll Swansea, Swansea, W Glam, Wales
关键词
medical records; standards;
D O I
10.7861/clinmedicine.3-4-329
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
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 are unlikely to be realised. The onus for improving records lies with individual health professionals. Structuring the record car bring direct benefits to patients by improving patient outcomes and doctors' performance. The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.
引用
收藏
页码:329 / 332
页数:4
相关论文
共 39 条
[1]  
ADAMS DCR, 1993, ANN ROY COLL SURG, V75, P96
[2]   COMPUTER-AIDED DIAGNOSIS OF ACUTE ABDOMINAL-PAIN - A MULTICENTER STUDY [J].
ADAMS, ID ;
CHAN, M ;
CLIFFORD, PC ;
COOKE, WM ;
DALLOS, V ;
DEDOMBAL, FT ;
EDWARDS, MH ;
HANCOCK, DM ;
HEWETT, DJ ;
MCINTYRE, N ;
SOMERVILLE, PG ;
SPIEGELHALTER, DJ ;
WELLWOOD, J ;
WILSON, DH .
BRITISH MEDICAL JOURNAL, 1986, 293 (6550) :800-804
[3]  
Audit Commission, 1999, SETT REC STRAIGHT RE
[4]  
Audit Commission, 1995, SETT REC STRAIGHT ST
[5]  
Belmin J, 1998, PRESSE MED, V27, P1519
[6]  
Bowns IR, 1999, HLTH INFORMATICS J, V5, P179, DOI DOI 10.1177/146045829900500402
[7]   DO PRIMARY-CARE PHYSICIANS PREFER DICTATED OR COMPUTER-GENERATED DISCHARGE SUMMARIES [J].
BRAZY, JE ;
LANGKAMP, DL ;
BRAZY, ND ;
DELUNA, RF .
AMERICAN JOURNAL OF DISEASES OF CHILDREN, 1993, 147 (09) :986-988
[8]   EFFECT OF MEDICAL RECORDS CHECKLISTS ON IMPLEMENTATION OF PERIODIC HEALTH MEASURES [J].
CHENEY, C ;
RAMSDELL, JW .
AMERICAN JOURNAL OF MEDICINE, 1987, 83 (01) :129-136
[9]   IMPROVING PHYSICIAN COMPLIANCE WITH PREVENTIVE MEDICINE GUIDELINES [J].
COHEN, DI ;
LITTENBERG, B ;
WETZEL, C ;
NEUHAUSER, DV .
MEDICAL CARE, 1982, 20 (10) :1040-1045
[10]  
*DEP HLTH, 2002, CM527