Making sense of the clinical record Flashcards
What is the function of the clinical record?
Support patient care with other HCPs
Improve future patient care for planning and management
Legal document that records treatment plans and investigations
Ensures care continuity
What is the basic structure of a clinical record?
Presenting symptoms and reasons for seeking health care
Relevant clincial findings
Diagnosis+ (differentials)
Care options
Discussion about risk and beenfits of care and treatment
Decisions about care and treatment
Outcome
What are the strengths of paper records?
Functionable and portable
Must be dated and signed
Writer identified
Continuous
What are the weaknesses of paper records?
Legibility issues
Structural issues that make it prone to damage
Less security protection compared to digital
Transportation
Environmental damage
What are the strengths of electronic records?
Audit trail
Searchable
Problem-orientated
Provides reminders and prescription alerts
Provides disease register
Structured
What are the weaknesses of electronic records?
Navigating system is complex and may require training
Open to web attacks and outages
More costly
Some practises may use a different system
What are the differences between hospital and GP records?
GP records are patient orientated and paper light with limited access for community teams and logistically secure.
Hospital records are paper-based, disease orientated, shared by all in hospital with slow and poor quality computerisation.
How do HCPs contribute to the record?
Record patient observations such as weight and bladder scan.
What are the strengths of the audit, management and research tool?
Uses data from clinical record to support clinical research
Facillitates risk management and clinical governance
What are the weaknesses and of the audit, management and research tool?
Third parties which have altered documents are not always identified
Limitations in time to conduct as it is time consuming
How should clinical records be recorded?
Objective and thorough comprehensive history
Examination of all the systems
Investigations and referrals are included
How should patient procedures be recorded in a clinical record?
Procedure type and indication
Confirmation of any allergies
Physical examination performed
Site of entry
Any issues during and after
Equipment and drugs used
