The need for mandatory clinical recording standards

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The development of standards must be led by clinicians rather than managers There must be assigned responsibility and accountability for recording of patient data

Clinical Medicine Vol 4 No 3 May/June Key Points
The quality of the information in electronic patient records
depends directly on the quality of data currently being
recorded in paper-based records
Standards for clinical recording are needed to assure that
consistent data are recorded in a structured and timely
manner
The development of standards must be led by clinicians
rather than managers
There must be assigned responsibility and accountability for
recording of patient data
Continuous monitoring of patient data is needed to assure
standards are met

information is not available, is not accurate, is not timely, or simply is not there when decisions are being made, a patient could die. That tragic possibility alone should be enough to mandate at least minimal record-keeping standards.

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