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PubMed · 8718103

Preparing for electronic documentation.

D Johnson·K Martin
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Abstract

Anticipating JCAHO review within 1 year, the nursing department developed and implemented a staff-developed manual system using Focus charting. Forms were developed that would be easily transferred to computerization.

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Forms and Records ControlHospital Information SystemsHumansMedical Records Systems, ComputerizedNursing RecordsPlanning TechniquesProfessional Staff CommitteesJournal Article

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D Johnson, K Martin. 1996. Preparing for electronic documentation.. https://pubmed.ncbi.nlm.nih.gov/8718103/

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The Netherlands have the 'Wet op de Geneeskundige Behandelingsovereenkomst', a law concerning the medical treatment agreement with the patient. Among other things it regulates the duties regarding the keeping and destruction of medical records. A critical evaluation is necessary, because the existing regulation is expected to have a negative effect on patient care and on scientific research. Development of better criteria for destruction of medical records is necessary. Until then, the destruction of medical records should be stopped.

Forms and Records Control↗