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.

    27/68 (page 21)
    that it is possible to confuse the name front sheet with the case history sheet which on occasions is also known as the front sheet and we recommend that the name ‘identification sheet’ should be used in future. (See Appendix A). 61. In considering the need for standardisation of the identification sheet we became aware that this is a key form for the extraction of statistical informa- tion essential for management and for epidemiological research. We realised that much has still to be done in applying hospital records for these purposes but we felt that processing of this sort of data is an inevitable and necessary evolution in the Health Service and we came firmly to the conclusion that we must look ahead to the time when extraction of data from hospital records is an essential function of the hospital administration. Workers who are the fore- runners in this field impressed us with the difficulties they now face in extracting even simple administrative details from hospital records because of their diversity. We were in no doubt therefore that we must recommend a standard layout for the identification sheet and one which as well as meeting the adminis- trative needs of the hospital must be suitable for modern methods of collecting and processing statistics. We did not think that there should be any conflict in these aims because we could not see that there need be any statistics collected which would not be of value in the administration of the hospital itself as well as for use in planning national needs. | 62. Whilst we are convinced of the need for more effective collection of statistical data from hospital records we appreciate the difficulties for hospital staff who have the job of extracting the information and we realise that it is difficult to maintain any enthusiasm in producing statistical information which is not of obvious value to the patients and to the hospital administration. Since much of the data requested is likely to be utilised on a regional or national basis, it may be difficult to convince hospital staffs of the importance of such data. The introduction of mechanisation will undoubtedly lead to the feeding back of regional and national data which should help hospital staffs to realise the importance of the accuracy of standardisation of the information they are called upon to collect (see paragraph 108). The comparatively limited co-operation with the Hospital In-Patient Enquiry when it was entirely voluntary illustrated the difficulty and we know that some hospital groups are still reluctant to send in the returns. We regard this as an entirely understandable attitude in the busy hospital service where the immediate needs of the patients dominate. We therefore decided that if possible the production of data for processing away from the hospital should be a by-product of the recording of information which was essential for the hospital’s own administration. 63. The solution we decided could be found in a procedure by which the Identification Sheet (HMR 1) would be the basic source document from which statistical information could be derived. After it is created and the ‘arrival’ part of the strip is completed, it should be photo-copied. The copy could first be held and used as an indicator of patients in hospital and might also be used to capture information at various stages of the patient’s progress. After discharge of the patient it would become a control document for the case folder, remaining outstanding on the file, until diagnosis, disposal and all statistical functions were completed. At this point, the copy of HMR 1 would become the form for using or sending forward for data processing. It could be used by the General Register