The standardisation of hospital medical records / report of the sub-committee.

  • Great Britain. Standing Medical Advisory Committee.
Date:
1965
Catalogue details

Licence: Public Domain Mark

Credit: The standardisation of hospital medical records / report of the sub-committee. Source: Wellcome Collection.

    10/68 (page 4)
    12. The functions of medical records described in paragraph 11, though unportant, do not directly affect doctors and nurses who treat the patient in hospital. We could hardly recommend standardisation if it did not bring positive advantages to them and direct benefit to their patients. The hospital doctor likes his medical records to be in. line with his personal practice of medicine, and as we remarked earlier, this has inhibited moves towards standard- isation. We do not however accept that the personal nature of a doctor’s service necessarily means that the forms he works with must be of his own design. Many hospital doctors do in fact work with record forms not of their own choice, though there is a tendency for a clinician to introduce case history forms to suit himself and for a radiologist or a’ pathologist to introduce his own system. But medical record systems cannot change with every change of con- sultant and since junior medical staff have little say in the choice-of forms they work with, diversity is not to be defended on the ground that it lets each doctor have the form he wishes, and its disadvantages are marked. Hospital doctors move between hospitals, particularly when in junior posts and even consultants may work in a number of different places. It is wrong that they should have to accustom themselves to different designs of forms in each hospital they work in. At best it is inefficient and._awkward and at the worst it can lead to mistakes. It should not be forgotten that nursing and administrative staff may have no part in the design of the forms with which they work every day. 13. Lack of standardisation is also a disadvantage when records have to be referred to other hospitals. 14. Perhaps the most serious argument against diversity of medical records is that it allows them to be underrated as an instrument in the discipline of medi- cine. The value of keeping good medical records is stressed in the training of medical students, but these good habits are hard to maintain among the con- fusion of documents which the hospital doctor meets later in his career. A desire for some sort of system may be seen in the way that certain records used in postgraduate medical schools have virtually imposed themselves as standards in some specialties. 15. Our consideration of the functions of medical records leads us to the conclusion that for all the purposes they serve standardisation is right in prin- ciple. Any system of standardisation must allow freedom to introduce new forms for special purposes or modifications dictated by changing medical or social needs. In the course of all our studies we learned nothing which caused us to reject standardisation as a practical proposition. In the pages which follow we therefore lay down the broad lines on which it should be started and we suggest the design of some of the basic forms. We also attempt to forecast the shape of future developments and proffer some suggestions about how they might be met. Il. MEDICAL RECORD TERMS 16. Medical record documents and procedures tend to be known by a number of different terms. Generally the alternative terms are well understood and there is no confusion. We felt howevei that in this report we ought to submit to our own views on standardisation and keep our references uniform to avoid risk of ambiguity. We have drawn up in Appendix A a glossary of medical record