Structured Clinical Records Flashcards
1
Q
Why do we need structured clinical records
A
- Patient safety
- Document evidence
- Clinical governanve
- Ongoing care
- Communication
- Improve services (audit)
- Professional standards
- Complaints
2
Q
What do we include in S.C.R
A
- PRF’s
- Referral letters
- Inpatient clerking
- Handover communications
- Discharge summeries
- Outpatient letters
3
Q
What are the minimum retention records for medical documentation
A
- No longer then 30 years unless under separate legislation
4
Q
Ambulance records kept for
A
10 years
5
Q
GP records
A
10 years
6
Q
Maternity records kept for
A
25 years
7
Q
Mental health records kept for
A
20 years
