Computerised versus handwritten records.
The death of Victoria Climbié highlighted the worst possible consequences of inadequate record keeping. A serious case review raised concerns about the quality of record keeping in the paediatric intensive care unit (PICU) of a large UK children's hospital and an audit was undertaken to compare the standard of handwritten nursing records in the PICU with that of the computerised nursing records in the high dependency unit (HDU). Record keeping in both PICU and HDU was found to be sub-standard in many respects. Both types of record keeping have their faults but the computerised system can potentially compensate for some of the errors and omissions that were apparent in the handwritten records. Nurses require regular training to reinforce record keeping knowledge and skills: this has been incorporated into the hospital's mandatory training programme.
Whyte
Mandi
M
Royal Liverpool Children's Hospital, Alder Hey.
D000004:Abbreviations as Topic; D019985:Benchmarking; D002648:Child; D002649:Child Abuse / Q000175:diagnosis / Q000517:prevention & control; D002983:Clinical Competence; D019983:Guideline Adherence / Q000592:standards; D017408:Guidelines as Topic; D006236:Handwriting; D006776:Hospitals, Pediatric; D006801:Humans; D015278:Intensive Care Units, Pediatric; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009730:Nursing Assessment / Q000592:standards; D009731:Nursing Audit; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000193:education; D010347:Patient Care Planning / Q000592:standards; D010371:Pediatric Nursing / Q000193:education / Q000592:standards; D006113:United Kingdom