Abstrakt
"Verba volant, scripta manent" (spoken words fly away, written words remain) Caius Titus. Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare.
Regardless of the form of the records (i.e. electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. 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).
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. 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.
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. There is also a list of suggested reading from several countries that may prove useful.