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Flashcards in Structured Clinical Records Deck (7)
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1

Why do we need structured clinical records

- Patient safety
- Document evidence
- Clinical governanve
- Ongoing care
- Communication
- Improve services (audit)
- Professional standards
- Complaints

2

What do we include in S.C.R

- PRF's
- Referral letters
- Inpatient clerking
- Handover communications
- Discharge summeries
- Outpatient letters

3

What are the minimum retention records for medical documentation

- No longer then 30 years unless under separate legislation

4

Ambulance records kept for

10 years

5

GP records

10 years

6

Maternity records kept for

25 years

7

Mental health records kept for

20 years