Making Sense of the Clinical Record

Question 1

State some components which should be included in a clinical record

Answer 1

• Symptoms + reasons for seeking healthcare
• Clinical findings
• Diagnosis + differentials
• Options for Care / treatment (safety nettings)
• Discussion of risks / benefits
• Discussion of care / treatment
• Action taken / outcomes

Question 2

What are some advantages to paper records?

Answer 2

1. They are familiar to users who do not require training to use it
2. They are portable
3. They do not experience down time like e-records do
4. Allows flexibility in recording “softer” data

Question 3

What are some disadvantages to paper records?

Answer 3

1. Legibility issues
2. Cannot be searched quickly
3. Susceptible to unplanned destruction i.e. fires / flooding
4. Only one original copy exists
5. Multiple records for different doctors

Question 4

What are some advantages to e-records?

Answer 4

1. Searchable
2. Can include significant imaging / technology content
3. Can be shared by all in a hospital
4. ICD code driven