Standards in medical record keeping

Clinical Medicine

Volumn 3, Issue 4, 2003, Pages 329-332

  Mann, Robin ^a   Williams, John ^b  

^a ROYAL COLLEGE OF PHYSICIANS   (United Kingdom)

^b SWANSEA UNIVERSITY   (United Kingdom)

Author keywords

Medical records; Standards

Indexed keywords

AUTOMATION; ELECTRONIC MEDICAL RECORD; EVIDENCE BASED MEDICINE; HEALTH CARE PERSONNEL; MEDICAL AUDIT; MEDICAL INFORMATICS; MEDICAL RECORD; MEDICOLEGAL ASPECT; NATIONAL HEALTH SERVICE; PATIENT CARE; PHYSICIAN; QUALITY CONTROL; REVIEW; STANDARDIZATION; TREATMENT OUTCOME; UNITED KINGDOM;

EID: 0042178341     PISSN: 14702118     EISSN: None     Source Type: Journal    
DOI: 10.7861/clinmedicine.3-4-329     Document Type: Review

References (39)

1. Ministry of Health Central Health Services Council. The standardisation of medical records. London: HMSO, 1965.
2. Weed LL. Medical records that guide and teach. N Engl J Med 1968;278:652-7.
3. Switz DM. The problem-oriented medical record: evaluation and management of anemia before and during use. Arch Intern Med 1976;136:1119-23.
4. Audit Commission. Setting the record straight - a study of hospital medical records. London: HMSO, 1999.
5. Audit Commission. Setting the record straight - a review of progress in health records services. London: HMSO, 1999.
6. Kennedy Report. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995. Command Paper; CM 5207. London: Department of Health, 2002.
7. Department of Health. Delivering 21st Century IT Support for the NHS - National Strategic Programme. 2002. London: DH, 2002.
8. NHS Information Authority. Information for health: an information strategy for the modern NHS 1998-2005. 1998. www.nhsia.nhs.uk/def/pages/info4health/1.asp
9. Welsh Assembly Government. Informing Healthcare. 2002.
10. Rogers JL, Haring OM. The impact of a computerized medical record summary system on incidence and length of hospitalization. Med Care 1979;17:618-30.
11. Humphreys T, Shofer FS, Jacobson S, Coutifaris C, Stemhagen A. Preformatted charts improve documentation in the emergency department. Ann Emerg Med 1992;21:534-40.
12. Zenni EA, Robinson TN. Effects of structured encounter forms on pediatric house staff knowledge, parent satisfaction, and quality of care. A randomized, controlled trial. Arch Pediatr Adolesc Med 1996;150:975-80.
13. Adams ID, Chan M, Clifford PC, Cooke WM et al. Computer aided diagnosis of acute abdominal pain: a multicentre study. BMJ (Clin Res Ed) 1986;293:800-4.
14. Duggan AK, Starfield B, DeAngelis C. Structured encounter form: the impact on provider performance and recording of well-child care. Pediatrics 1990;85:104-13.
15. Lilford RJ, Kelly M, Baines A, Cameron S et al. Effect of using protocols on medical care: randomised trial of three methods of taking an antenatal history. BMJ 1992;305:1181-4.
16. Wallace SA, Gullan RW, Byrne PO, Bennett J, Perez-Avila CA. Use of a pro forma for head injuries in the accident and emergency department - the way forward. J Accid Emerg Med 1994;11:33-42.
17. Goodyear HM, Lloyd BW. Can admission notes be improved by using preprinted assessment sheets? Qual Health Care 1995;4:190-3.
18. Teo S, Hanson R, Van Asperen P, Giles H et al. Improving asthma documentation in a paediatric emergency department. J Paediatr Child Health 1995;31:130-3.
19. Robinson SM, Harrison BD, Lambert MA. Effect of a preprinted form on the management of acute asthma in an accident and emergency department. J Accid Emerg Med 1996;13:93-7.
20. Belmin J, de la Fourniere F, Bellot P, Medjahed S et al. Quality of the information collected during admission to a hospital geriatric service: importance of a structured medical record. Presse Med 1998;27:1519-22.
21. Johns MB, Hovell MF, Drastal CA, Lamke C, Patrick K. Promoting prevention services in primary care: a controlled trial. Am J Prev Med 1992;8:135-40.
22. Shank JC, Powell T, Llewelyn J. A five-year demonstration project associated with improvement in physician health maintenance behavior. Fam Med 1989;21:273-8.
23. Cohen DI, Littenberg B, Wetzel C, Neuhauser D. Improving physician compliance with preventive medicine guidelines. Med Care 1982;20:1040-5.
24. Irtiza-Ali A, Houghton CM, Raghuram A, O'Driscoll BR. Medical admissions can be made easier, quicker and better by the use of a preprinted Medical Admission Proforma Clin Med 2001;1:327.
25. Cheney C, Ramsdell JW. Effect of medical records' checklists on implementation of periodic health measures. Am J Med 1987;83:129-36.
26. Wrenn K, Rodewald L, Lumb E, Slovis C. The use of structured, complaint-specific patient encounter forms in the emergency department. Ann Emerg Med 1993;22:805-12.
27. Town I, Kwong T, Holst P, Beasley R. Use of a management plan for treating asthma in an emergency department. Thorax 1990;45:702-6.
28. Wyatt JC, Wright P. Design should help use of patients' data. Lancet 1998;352:1375-8.
29. O'Driscoll, B. R. Personal communication. 2003.
30. Wright P, Jansen C, Wyatt JC. How to limit clinical errors in interpretation of data. Lancet 1998;352:1539-43.
31. Adams DC, Bristol JB, Poskitt KR. Surgical discharge summaries: improving the record. Ann R Coll Surg Engl 1993;75:96-9.
32. Bowns I R, Newton P, Long S, Walters S et al. Testing headings for communicating the personal health record: comparison from recipient's perspective. Health Informatics J 1999;5:179-87.
33. Brazy JE, Langkamp DL, Brazy ND, De Luna RF. Do primary care physicians prefer dictated or computer-generated discharge summaries? Am J Dis Child 1993;147:986-8.
34. Howard DJ. Structured discharge letter in a department of geriatric medicine. Health Trends 1986;18:12-4.
35. Rawal J, Barnett P, Lloyd BW. Use of structured letters to improve communication between hospital doctors and general practitioners. BMJ 1993;307:1044.
36. van Walraven C, Duke SM, Weinberg AL, Wells PS. Standardized or narrative discharge summaries. Which do family physicians prefer? Can Fam Physician 1998;44:62-9.
37. Essex B, Doig R, Rosenthal J, Doherty J. The psychiatric discharge summary: a tool for management and audit. Br J Gen Pract 1991;41:332-4.
38. Williams JG, Mann RY. Hospital episode statistics: time for clinicians to get involved? Clin Med 2002;2:34-7.
39. Royal College of Physicians. Laying the Foundations for Good Medical Practice: A generic training programme for senior house officers. Report of a working party. London:RCP, 2003.