MAKING SENSE OF THE CLINICAL RECORD

Question 1

what are some functions of the clinical record?

Answer 1

record of contact with healthcare providers
facilitates communication with and about patients
makes info available to others with access to the system
stores info received from other partners e.g. lab results
improves future patient care
for social purposes at the request of patients
medico-legal document
makes transfer to any NHS practice simple
supports teachng
supports professional appraisal and revalidation
supports population research

Question 2

what are the general principles of recording notes?

Answer 2

be professional, support patient care, make notes high quality, share notes with patient to improve accuracy and support patient-doctor relationship, must be stored and handles security

Question 3

what are advanatges of paper medical records?

Answer 3

reduced upfront costs, ease of use in familiar format, physical form factor, easier to customise

Question 4

what are disadvanatges of paper medical records?

Answer 4

storage isnt scalable
lack of backups and limited security
time consuming and error prone
inconsistent layouts
no clear audit trail