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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References in periodicals archive ?
A registered nurse (RN), "Mrs L", who inappropriately accessed the electronic clinical records of nine different people on 19 different occasions between January and September 2011, has been censured and fined $6000.
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.
TOPCON'S I-CLARITY Practice Management System has introduced full clinical records and contact lens clinical records modules, complete with an optional prescreening facility.
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.
We also know that their clinical records reflect nothing about where that patient would stay, or access mental health services once here.
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.
These and many more possible concerns created an excellent opportunity for members attending to keep their clinical records in A1 condition now that the Health Fund units are conducting audits to ensure practitioners are keeping sufficient client clinical records.
Six sets of patient's bedside notes and a further six sets of clinical records were deemed sub-standard.
More than 70 percent-of respondents said their organizations lack staff to implement clinical records software and 76 percent said they were concerned about retaining current IT staff.
Like clinical records now, these EHRs will be completed by clinicians, and with SNOMED CT content supporting the EHR the clinician will be routinely selecting and entering SNOMED CT terms (where appropriate).
Years before my employment, C4 had understood the importance of standardizing its clinical procedures and processes for data collection; these methods had been implemented and maintained largely through the work of Director of Clinical Records Noemi Rivera, RHIA.
In assessing whether a nurse's duty of care has been met in accordance with accepted standards, a judge will assess the evidence that is provided by one's professional peers, and reference will also be made to the patient's clinical records.

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