[High quality medical records--high quality medicine].
The medical record is both an indicator of the quality of care, and a means of improving this quality. In addition to being a source of information and a means of communication in the care of patients, the medical record is also becoming a document of increasing legal importance. The content and design of medical records, and how they are kept, should comply with legal requirements. The patients' right to read their own records is well established in Norway. Incomplete records and lack of information will always be held against the doctor in the case of complaints or lawsuits. The medical record provides a good basis for evaluation of care, and a systematic evaluation of medical records, e.g. in groups, is an effective form of medical audit. While the authorities are making an effort to achieve better standardization of medical records, every medical practitioner should do his best to let the everyday use of medical records become an important part of his personal quality assurance.
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Tidsskrift for Den norske laegeforening, Lysaker.
D006801:Humans; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards*; D009664:Norway; D011785:Quality Assurance, Health Care; D011787:Quality of Health Care
Gode journaler er god medisin.