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.

    39/68 (page 33)
    than others. To meet this particular problem which is most important in psychi- atric hospitals, it is suggested that any documents of a highly confidential nature, should be kept inaspecially marked and sealed envelope, HMR 250, and be retained as a primary document, instructions being given to this effect. 106. The system of registration suggested for the identification sheet should prove very valuable to psychiatric hospitals since it will assist in the relating of previous incidents where the individual has been admitted to any hospital in the United Kingdom after the date of the general adoption of the identification sheet. 107. There are many systems of filing but the suggestions proposed could readily be adopted to meet the requirements of a psychiatric hospital. The importance of the discharge summary and the preparation of periodic summaries of the out-patient record should enable the essential data to be easily filed and obviate the necessity for combing through haphazardly arranged records. The essential history could be up-dated to be included with the records of the latest incident and only new facts recorded, thus avoiding unnecessary wastage of time and duplication of records. xX. MECHANICAL SYSTEMS AND DATA PROCESSING 108. The medical records of the hospital service, together with those of the other branches of the National Health Service, provide a unique mass of information of inestimable value for the management of the service and for epidemiological and clinical research. Efforts to utilise this information come up against the barriers of inaccessibility and lack of standardisation. The standardisation of medical records is an essential preliminary to the efficient utilisation of mechanisation. We hope that this report will encourage the adoption of standardised methods for the recording of essential data on hospital and other clinical records. But even after standardisation has been achieved, manual methods of extraction are expensive in both medical and clerical time. Many problems remain unsolved because few people have the energy and patience to undertake the laborious task of sorting and extracting records manually. 109. In the business world almost every organisation the size of the Health Service now employs some or all of the many methods of mechanisation avail- able for the recording, transport and storage of records and essential data. This applies even when the businesses have a diversity of units of very differing sizes so that the particular problems of the Health Service are not such as to make it impossible to utilise efficiently some of the newer methods of mechanisation. Mechanisation should not be considered as a new fangled idea or the latest craze, but merely as an extension of the typewriter, the slide rule and the adding machine. The great advantage of electronic systems is their capacity for storage and speed of working which can remove so much of the tedium of routine re- cording as well as providing built-in methods for checking accuracy. 110. There are two broad classes of electronic computing equipment available for the processing of medical and hospital data, the digital computers and the analogue computers. The latter, whilst very efficient in making analyses, are more limited in their range of usage but they have the advantage that they can 53