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.

    28/68 (page 22)
    Office, and/or for linkage studies and/or local processing as necessary. The first stage in producing statistics must be to feed back activity information rapidly to the hospitai itself. The next stage is to provide regional and national tabulations as at present produced by the Hospital In-patient Enquiry of the General Register Office. HMR 1, being a summary with a content that it is hoped will be common to all hospitals, will serve these statistical purposes and as the system evolves, possibly others in the future. 64. The upper half of the identification sheet (see fig. 2) contains standard registration particulars, with some additions, which are commented upon in paragraph 67. The form will be completed manually, but could also be used with a labelling system. For this reason we recommend a sheet and not the printing of identification details on the inside of the case folder because (a)-of the diffi- culty of copying either by carbon or photo-reproduction, and (b) because covers are frequently damaged and liable to be replaced. 65. In the lower part of the sheet there are three positions for admission or new attendances. HMR | is intended to be used for either in-patient or out- patient registration but this_arrangement will not invalidate its use for data processing of either in-patient or out-patient statistics. It may be necessary to reserve one of the spaces for special purposes. Psychiatric records require special administrative details in addition to those already available on HMR 1 and it is conceivable that special requirements may be necessary for the accident service. There is a further value in keeping one of the spaces free in that it will encourage hospitals to experiment with developments. 66. We have consulted the General Register Office about the details which they would need on the form and they are satisfied that these fulfil their require- ments as far as can be foreseen. The subject of hospital statistics is however still in a stage of early development but we feel that the unification of the Identific- ation Sheet and the statistics is a desirable step and we hope that it will be intro- duced in all hospitals at a very early date. However we also realise that the details we have included in our design may require considerable further con- sultation. 67. Few of the entries on the form call for any explanation since they are already included on the majority of identification sheets at present in use. Some however are not so obvious. The space for maiden name as well as married names is included for two reasons. It ensures association with previous medical records and it is of great advantage to ad hoc research calling for record linkage with other branches of the Health Service, and with birth records when family linkage is involved. 68. The spaces for particulars of diagnosis may appear inadequate to those who use the International Statistical Classification of Diseases, Injuries and Causes of Death. We are advised however that in many hospitals, often through inadequate staffing, it 1s difficult to get completion of even the basic diagnoses. We have therefore been compelled to modify our ideals by accepting the minimal requirements and for the present those hospitals who use a better classification may need to provide a special sheet in the folder for this purpose. pe