Week 6 - Making Sense Of The Clinical Record

Question 1

Overall Functions of the clinical record

Answer 1

: support patient care by keeping a record of contact with all health care providers and aide memoire to facilitate communication with and about patients

: improve future patient care

• audit
• financial planning
• management
• research

:social purposes at the request of patients

: medico-legal document

Question 2

General principles of recording

Answer 2

• defines the professionalism of the writer
• support patient care
• secondarily support audit , teaching and research
• high quality
• sharing with patients improves accuracy and supports the doctor - patient relationship
• stored and handled securely

Question 3

What to record

Answer 3

• presenting symptoms and reasons for seeking healthcare
• relevant clinical findings
• diagnosis and important differentials
• options for care and treatment (incl safety netting )
• discussion about risks and benefits of care and treatment
• decisions about care and treatment
• action taken and outcomes

Question 4

How to record

Answer 4

Professionally
Contemporaneously
Comprehensively
Permanently