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Electronic records

File 139761Across healthcare there is a need for an efficient and transparent means of recording, transmitting and accessing reliable clinical information in order to deliver high-quality care to patients.

Published in February 2013, The Francis Report emphasised the need for better information and highlighted the risks that increasing service pressures bring to patients.

It is increasingly accepted that these challenges can only be met by the development and use of electronic health records in which data are recorded consistently across all contexts.

Initiatives such as the Common User Interface (CUI) programme, developed by the Health and Social Care Information Centre (HSCIC), are working to standardise components within the electronic health record to ensure increased familiarity with screen layouts.

This should lead to improved patient safety, increase clinician effectiveness and efficiency, and reduce training and support costs as staff move between employers using the common interface within their systems.

However, those physiotherapy staff working in organisations that have not invested in such initiatives, may be called upon to do the thinking about what to include in a record keeping template, and how to ensure a professional approach is adhered to within organisation-wide record keeping practice.

For more information on IT security specifically for small and medium businesses visit the Information Commissioners Office (ICO).

Electronic record-keeping and the Cloud

A number of professionals, particularly those in private practice, are looking to the Cloud to help in their move toward electronic record keeping.

The ICO has produced guidance on the use of the Cloud for members of the public and more general information for organisations.

Key considerations should be made when considering using the Cloud for electronic record keeping, these include:

  • Whether the specific technical capabilities of the system enable the required regulatory, professional and legal standards of clinical record keeping to be met
  • The need to be able to distinguish the entries in the record made by the different members of staff involved in delivering care to the patient
  • Ensuring confidentiality is protected
  • The system needs to be secure and adequately backed up in case of theft or damage
  • Data storage limits should be sufficient to ensure the necessary storage and retention of records is achievable now and in the future

E-health in Scotland: useful documents


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