Ch 2 purposes of health records

Chapter 2 - The Purposes of Health Records

These will be reviewed under the headings of: clinical, non-clinical, additional and emerging purposes.

2.1 Clinical purposes

Traditionally primary and community care health professionals require patient record systems that have the following functionality:

• Facilitate the clinical care of individual patients by:

  • Assisting the health professional to structure his or her thoughts and make appropriate decisions

  • Acting as an aide memoir for the health professional during subsequent consultations

  • Making information available to others with access to the record system who are involved in the care of the same patient

  • Providing information for inclusion in other documents (e.g. laboratory requests, referrals and medical reports)

  • Storing information received from other parties or organisations (e.g. laboratory results and letters from specialists)

  • *Transfer the record to any NHS practice with which the patient subsequently registers (GP record) *

  • Providing information to patients about their health and health care

• Assist in the clinical care of the practice population by:

  • Assessing the health needs of the population

  • Identifying target groups and enabling call and recall programmes

  • Monitoring the progress of health promotion initiatives

  • Providing patients with an opportunity to contribute to their records

  • Supporting medical audit

2.2 Non-clinical purposes

Health organisations also need a patient record system that can be used to meet administrative and contractual obligations by:

• Providing medico‑legal evidence (e.g. to defend against claims of negligence)

• Providing legal evidence in respect of claims by a patient against a third party (e.g. for injuries, occupational diseases and in respect of product liability)

• Providing reports and information for third parties (e.g. insurance companies)

• To support claims for benefits and other additional social support

• Recording when and to whom such evidence is provided

• Meeting the requirements of specific legislation on subject access to personal data and health records

• Recording the preferences of patients in respect of access to and disclosure of information they have provided in confidence

• Providing evidence of workload within a health organisation

• Providing evidence of workload to support claims and bids for resources

• To enable commissioning of community and secondary healthcare services

• Monitoring the use of external resource usage (e.g. prescribing, laboratory requests and referrals)

2.3 Additional purposes

Health organisations are increasingly likely to require a patient record system that can be used:

• To interact with a decision support/expert-system (likely to become a core clinical requirement)

• To support teaching and continuing medical education

• To support clinical governance activities

• To implement security and access control regimes for patient confidential information

• To support professional appraisal and revalidation

• To enable:

  • Epidemiological monitoring

  • Surveillance of possible adverse effects of drugs

  • Clinical research

2.4 Emerging purposes

Health records created in one health environment are increasingly likely to be accessed for viewing and/or editing in other health environments for example:

• A read-only shared record following an act of publication (e.g. the SCR in England and the ECS in Scotland)

• A read-only system giving access to an external electronic health record system (e.g. Graphnet)

• Read and write access to a single logical record - or separate records (e.g. TPP SystmOne & EmisWeb respectively)

• A shared record dependent on messaging (e.g. pathology request and report)

• Interfacing with medical devices : telehealth/telecare

• New requirements for patients to have increasing control of their health records[^1]

The main health benefits of shared records are likely to be improvements in the quality and safety of care, in access to care or in cost effectiveness.

This has important implications for clinical record keeping in terms of data quality, semantics, clinical coding, staff education and training. Making health records "fit for sharing" will require health professionals to think in new ways about clinical record keeping and what it means to use and create genuinely "inter-operable" electronic patient records that can be safely shared with other health professionals and patients.

[^1]: Equality and Excellence http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117794.pdf