![]() ![]() The advantages and disadvantages of keeping good or poor clinical records, respectively, is summarised in Table 1. Therefore, never forget the seventh principle of the Caldicott report, an NHS report on patient information, which says “ the duty to share information can be as important as the duty to protect patient confidentiality”. Finally, poor clinical records might have a profound impact on a patient’s lifelong health. Moreover, there is a benefit to the healthcare organisation in that good clinical records facilitate decision making for a single patient, thus freeing up time that can be spent with patients most in need. This, in turn, will benefit the patient through less time lost on repeating tests and by averting inaccurate diagnoses or the prescription of inappropriate treatments. Making sure that clinical notes are up to date and completed accurately with sufficient information will ensure that the proper information is provided to all relevant healthcare workers and will aid them in potential future decisions. Continuity in clinical notes is of vital importance to patient care as, in the current medical environment, many different healthcare professionals are involved in the treatment of a single patient. This is of particular relevance in the case of a contested medical decision but most importantly it ensures continuity. Remember, if you did not write it down, it did not happen. By documenting all relevant clinical information you are recording this information for future reference. Good clinical notes document the medical history of the patient. “Verba volant, scripta manent” (spoken words fly away, written words remain)Caius Titus There is also a list of suggested reading from several countries that may prove useful. In this issue of Breathe we will present the importance of keeping good clinical records, ways of facilitating this and an overview of legal aspects linked with clinical record keeping. Clinical records are also valuable documents to audit the quality of healthcare services offered and can also be used for investigating serious incidents, patient complaints and compensation cases. Should the need arise patients themselves should have access to their records to be able to see what has been done and what has been considered. Consequently, clinical records should be updated, where appropriate, by all members of the multidisciplinary team that are involved in a patient’s care (physicians, surgeons, nurses, pharmacists, physiotherapists, occupational therapists, psychologists, chaplains, administrators or students). electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. ![]() ![]() Regardless of the form of the records ( i.e. Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. ![]()
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