PubMed Health⌕ Search
Home/Archive/PubMed

PubMed · 16755895

Information governance: practical implications for record-keeping.

Christine Hutchinson·Christine Sharples
View original source ↗Export metadata ↓

Abstract

This article outlines nurses' legal and professional responsibility to adhere to good practice in keeping patients' notes up to date. It provides a description of information governance issues, including paper and electronic records. The article discusses wider issues such as the importance of good communication in record-keeping and advises on good practice in content and style.

Explore related subjects

ConfidentialityDocumentationHumansMedical RecordsNational Health ProgramsNurse's RoleUnited KingdomJournal Article

Keep this discovery

Explore connections, maps & timelines

BibTeXRIS

Christine Hutchinson, Christine Sharples. Information governance: practical implications for record-keeping.. https://doi.org/10.7748/ns2006.05.20.36.59.c4155

Cite the original work for its findings. Save a collection to share your selection of sources.

KEEP EXPLORING

Related citations

PubMed2007

The guideline of the personal health data structure to secure safety healthcare. The balance between use and protection to satisfy the patients' needs.

PURPOSE: To inform about the impact of a recent movement towards a policy to develop integrative networked electronic health record (EHR) as a basis for cooperation among care teams and with patients and in support of safe patient care in Japan. METHODS: The author headed a commission developing policy for health record (HR) structure and its computerization. It executed two questionnaire surveys as the basis for its work. One survey assessed the current state of computerization of health record in the hospitals certified by Japan Council for Quality Health Care (JCQHC). The other survey assessed the attitudes towards a specific EHR system in the Hiroshima University Hospital and its affiliate hospitals. RESULTS: The survey of the above hospitals showed that most have computer supported administrative procedures, but only few computer-based health records. The attitudes of the Hiroshima EHR users show that while they expect efficiency and quality improvements, there is also apprehension that the system in use might lower practical efficiency and compromise patient safety. Accordingly, health recording requirements and storage policy have been restructured and communicated to the hospitals. CONCLUSION: These insights led to the initiation of curricula educating "Health Information Technologist" which is promoted by Japan Association Medical Informatics and the criterion of Chart Review Promotion of JCQHC. They will also lead to recommendation for improved and advanced EHR.

Confidentiality↗
PubMed2007

Mortality in Iraq.

Explore the source record for details and available documents.

Confidentiality↗
PubMed2007

The HIV code.

Explore the source record for details and available documents.

Confidentiality↗