10 principles of good record keeping

H\0 In their ethical guidance, the General Medical Council lists several key pieces of information which must be included within a clinical report. 10 record keeping tips for medical records 1. This good record keeping practice ensures that future clinicians has a complete picture of the information on which a patient's treating be based at any spot in time. FOIA Most importantly, do not delete the information from the record as treatment, care or a procedure could have been given to the patient based on this information. Good record-keeping is central to the scientific process.14 Good research records encompass much more that just research data. If an entry is found to be factually incorrect, a signed and dated note with the alteration should be added to the medical record. The focus groups were particularly helpful in refining the best practices. When taking an audio or visual recording, its essential to be completely transparent with patients about how the record will be used and what happens to the recording following the interaction (i.e. DeliveryOwn-Collection, Archiving with Filing Room once filled Cited Here. Secure document storage in East Africa. H\n 2tAZG:!o_ d }Nv:#.8X Vv=x Don't miss the key details One of the most important principles of good record keeping is to take comprehensive notes in the first place. Nurses must learn the principles of good record keeping, because these records serve as a history of client care, reveal patterns in a patient's progress, guide future care decisions,. Because LIMS systems need to be customized for each process they handle, such systems are therefore viewed as being too inflexible for the typical academic laboratory.12 The exceptions here are areas like genomics and proteomics, whose procedures have become highly standardized with a need to process high amounts of data. All Rights Reserved, Kenyan business in 2021: What you need to know about opening up in December and a potential revolution of enterprise, How correspondence management fits within a companys wider records management system, File and document management for Kenyas legal sector, Inefficient records management could mean businesses are sitting on a ticking bomb, How an effective records management system will optimise your companys HR department, CCTV with Recording and Internet Viewing Capability.