Making sense of clinical records

Question 1

What are the functions of the clinical record?

Answer 1

1. Support patient care
   - Record of contact with health care providers
   - Aide memoire to facilitate communication with and about patients
2. Improve future patient care
   - Audit
   - Financial planning
   - Management
   - Research

Question 2

What are the different medical functions of the clinical record?

Answer 2

1. Support method of, and structure to, history and examination
2. Ensure clarity of diagnosis
3. Record treatment plans
4. Enable comprehensive monitoring
5. Help maintain a consistent explanation for the patient
6. Ensure continuity of care

Question 3

Give some of the purposes of medical records

Answer 3

1. Assist the healthcare professional to structure his or her thoughts and make appropriate decisions
2. Acting as an aide memoir for the professional during subsequent consultations
3. Making information available to others with access to the record system who are involved in the care of the same patient
4. Providing information for inclusion in other documents
5. Storing information received from other parties or organisations
6. Transfer the record to any NHS practise with which the patient subsequently registers
7. Assist in the clinical care of the practice population by:
   - assessing the health needs of the population
   - identify target groups and enabling call and recall groups
   - monitoring the progress of health promotion initiatives
   - providing patients with an opportunity to contribute to their records
   - supporting medical audits

Question 4

Give some non-clinical purposes of medical records

Answer 4

1. Providing medico-legal evidence
2. Providing legal evidence in respect of claims by a patients against a third party
3. Providing reports and information for third parties
4. Meeting the requirements of specific legislation on subject access to personal data and health records
5. Providing evidence of workload

Question 5

Give some emerging purposes of medical records

Answer 5

1. Manage cost-effective prescribing
2. Interfacing with medical devices and supporting tele-health and tele-care activities
3. New requirements for patients to have increasing control of their health records
4. A read-only shared record

Question 6

What is the basic structure, what is written, in a medical record?

Answer 6

1. Presenting symptoms and reasons for seeking health care
2. Relevant clinical findings
3. Diagnosis and important differentials
4. Options for care and treatment (incl. safety netting)
5. Discussion about risks and benefits of care & treatment
6. Decisions about care and treatment
7. Action taken and outcomes

Question 7

What makes a good clinical records?

Answer 7

• Good clinical records will allow a clinician to reconstruct a consultation or patient contact without relying on memory:
  1. Comprehensive history

2. Examination of patient
3. All systems explained
4. All important findings
5. Differential diagnosis
6. Investigations
7. Referral
8. Information given to patient
9. Consent
10. Treatment
11. Follow-up arrangements
12. Progress