Clinical Records

Clinical Records

 

the basic medical document compiled for every patient who applies to a medical treatment and prevention center.

The clinical record contains a basic information section (family name, given name, patronymic, age, family status, occupation), information on previous diseases, data on current illness, and the results of examination and treatment. Changes in the patient’s condition and the course of his illness are entered in the clinical record at the polyclinic at each visit, and in the hospital, daily. In the event of the patient’s death, an official report of the pathologicoanatomic autopsy is included. When the patient is discharged or transferred to another medical institution, or in the event of his death, the general conclusions of the attending physician (the epicrisis) is entered. The clinical record ensures continuity in the application of therapeutic and preventive measures by all physicians who observe the patient. When necessary, the clinical record serves as material for legal and forensic inquiry.

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We cannot answer that as of now because our experts are still studying the clinical records," Duque explained.
Duque, however, clarified that there was no conclusion yet on whether Dengvaxia had caused their deaths, explaining that a panel of Philippine General Hospital independent experts were currently evaluating their clinical records.
MPs slammed health chiefs for failing to reassure patients after losing 700,000 clinical records in the post.
A REGISTERED nurse who accessed the electronic clinical records of 64 people not under her care has been found guilty of professional misconduct, censured and had her registration suspended for 18 months.
The data extracted from clinical records at the eight health centers in the Los Andes Network were entered into an Excel[R] database with drop-down lists.
According to the tender, "It is essential that these clinicians are supported by the availability of clinical records such as Summary Care Record (SCR) and ESCR as well as electronic prescribing and other locally available systems.
The i-Clarity software is said by the company to combine "best of breed" point of sale and financial control systems, with full clinical records, dispensing and ordering systems--all in a single package.
Medibank Private requires Clinical Records to be taken in English.
During the process of the implementation of the programme, Women's Hospital will replace their existing paper-based patient clinical records system with a new electronic CIS.
There are also national guidelines for the content of clinical records for use across disciplines, developed by the Health and Social Care Information Centre and the Academy of Medical Royal Colleges (www.
Betsi Cadwaladr University Health Board confirmed they are reviewing clinical records from the summer of 1978 when the Wrexham Maelor was known as the Maelor General Hospital.
Six sets of patient's bedside notes and a further six sets of clinical records were deemed sub-standard.

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