The need for mandatory clinical recording standards.
Current health information initiatives and targets set by the UK government have brought about a flurry of activity in the National Health Service to try to reach those targets. One target is to implement an electronic patient record system as a replacement for the present paper-based system of record keeping. However, this will not be an easy task; simply introducing information technology into an already chaotic system will only compound existing problems. This article highlights the gaps that must be filled before an electronic record system can be effectively implemented. The two major elements that are missing are mandatory clinical recording standards and a profession that is responsible for monitoring and enforcing those standards. Some examples of relevant standards for clinical recording are provided and the role of a health information management profession is described.
Huston
Janis L
JL
Southeast London Strategic Health Authority. jangeorg@yahoo.com
D004282:Documentation / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D009313:National Health Programs; D006113:United Kingdom