A quality medical record is amongst the most sensitive
of personal records and great care should be taken to ensure the safe holding
of such record. The health care provider’s defense if assessment or decisions
are ever scrutinized; however, the primary aim for the patient record is to
enable health care providers communicate with themselves. Clinical records are
the most important and basic of clinical tools, aggregated to form a permanent
of individual consideration and the reasons for decision making. Essential for
effective communication and good clinical care, but they are often accorded low
priority, and poorly maintained, not readily available, independent inquires.
Practices points for a fit purpose structure, multidisciplinary records to
support good care and protect the interest of patient and health care
providers. (Kayode & Osundina, 2008).
of personal records and great care should be taken to ensure the safe holding
of such record. The health care provider’s defense if assessment or decisions
are ever scrutinized; however, the primary aim for the patient record is to
enable health care providers communicate with themselves. Clinical records are
the most important and basic of clinical tools, aggregated to form a permanent
of individual consideration and the reasons for decision making. Essential for
effective communication and good clinical care, but they are often accorded low
priority, and poorly maintained, not readily available, independent inquires.
Practices points for a fit purpose structure, multidisciplinary records to
support good care and protect the interest of patient and health care
providers. (Kayode & Osundina, 2008).
Apart from their sensitive nature, there is also used
practical consideration that they can be of considerable clinical value in
relations to on gong care of patient their primary purpose is to document the
assessment underlying the progress of the patient care. As month or year may
elapse between treatment or illness and staff may have moved on, the record
should serve to reconstruct event at a later data without recourse to memory.
practical consideration that they can be of considerable clinical value in
relations to on gong care of patient their primary purpose is to document the
assessment underlying the progress of the patient care. As month or year may
elapse between treatment or illness and staff may have moved on, the record
should serve to reconstruct event at a later data without recourse to memory.
Poor records keeping can lead to patient care being
adversely affected through, an increased risk of medication or other treatment
being duplicated or omitted, communication problems between staff, both
nursing, medical and paramedical personnel, a failure of focus attention on
early signs of changes in a patient condition and failure to place on records
significant observation and conclusions.
adversely affected through, an increased risk of medication or other treatment
being duplicated or omitted, communication problems between staff, both
nursing, medical and paramedical personnel, a failure of focus attention on
early signs of changes in a patient condition and failure to place on records
significant observation and conclusions.
The quality of health records keeping has the
potential to improve the quality, safety and efficiency of care when fully
implemented. They can also be of great importance in cases alleging medical
negligence, or other such litigations and there will be value to provide; of
course that their release is justified in any particular case. The information
contained in the health records allows health care providers to determined the
patient’s medical history and provide informed decision to care and provide
quality service in patients, provide serves, as in planning patient care, documenting
communication among patient and health care provider (professional) contributing
to the patient care (Hill & Jim, 2009).
potential to improve the quality, safety and efficiency of care when fully
implemented. They can also be of great importance in cases alleging medical
negligence, or other such litigations and there will be value to provide; of
course that their release is justified in any particular case. The information
contained in the health records allows health care providers to determined the
patient’s medical history and provide informed decision to care and provide
quality service in patients, provide serves, as in planning patient care, documenting
communication among patient and health care provider (professional) contributing
to the patient care (Hill & Jim, 2009).
Good health delivery can be achieved only with good
communications and shared clinical perceptions of a patient’s problems and needs.
Indefectible care is difficult to achieve without indefectible information.
Quality health records keeping do more than support good patient care, they are
essential to it, this is exemplified by the standard set out by the General
Medical Council (2011) and Royal College of Psychiatrists (2004). Quality
records keeping remains the most tangible evidence of a care given to a
patient. A quality health records keeping in hospital or an outpatient clinical
do not just happen, it requires the co-operation from doctors, nurses and other
members that contribute to patient health records. The skills of medical and
paramedical specialist are required to give complete care to the patient since
health record must contain sufficient data, written in sequence of event, to
justify the diagnosis and warrant that treatment and end result. It is
necessary that there be prompt recording of observation, treatment and care by
all that contributed to the care of the patient (Bales, 2003).
communications and shared clinical perceptions of a patient’s problems and needs.
Indefectible care is difficult to achieve without indefectible information.
Quality health records keeping do more than support good patient care, they are
essential to it, this is exemplified by the standard set out by the General
Medical Council (2011) and Royal College of Psychiatrists (2004). Quality
records keeping remains the most tangible evidence of a care given to a
patient. A quality health records keeping in hospital or an outpatient clinical
do not just happen, it requires the co-operation from doctors, nurses and other
members that contribute to patient health records. The skills of medical and
paramedical specialist are required to give complete care to the patient since
health record must contain sufficient data, written in sequence of event, to
justify the diagnosis and warrant that treatment and end result. It is
necessary that there be prompt recording of observation, treatment and care by
all that contributed to the care of the patient (Bales, 2003).
