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Box 2 Main components of the six levels of the electronic patient record Level 1 Patient administration systems; computerised appointments; case note medic news standalone pathology records Level 2 Common patient identifier across department systems; out-patient clinic modules Level 3 Computerised support for assessment, care planning, investigation requests, electronic prescribing, care medic news Level 4 Linked knowledge and research to information management and medic news clinical care medic news decision support systems; electronic prescribing linked to evidence-based medicine Level 5 Majority of clinical information stored in EPRs; advanced workflow; speciality modules Level 6 High-speed networks; advanced data-input devices; full case notes online; teleconferencing The development of electronic records and communications will further highlight the need for common standards of information organisation for communicating and teamworking.

It is essential that day-to-day health communications within a multi-disciplinary team convey the necessary detail and meaning. They should also be couched in an easily understandable common (standard) language and format, which, unfortunately, free text does not always confer. Nor, however, do some of the classification systems outlined here provide sufficient detail and meaning for everyday practice.

The dilemma arises that most classification or medic news systems use fully structured records, or set templates, suitable for electronic communication; in our own records, however, we medic news other health professionals usually use free text.

Communication within the NHS is not good and we sorely need standards governing information exchange for medic news clinical communications (Clinical Systems Group, 1998). The ideal might be a system that combines the advantages of structured records with the richness of free text. Sharing information has been shown to improve record-keeping (Reference Johnston, Langton and HaynesJohnston et al, 1994) and it might improve outcomes.

Adequate written communication is essential for good teamworking, particularly for hand-over, referrals within and to other specialities and in multi-disciplinary care. Medic news these situations, the main source of the information communicated is the health record. The quality of the record determines the quality of the information contained in communications between medic news of a team, and thus a standard that can provide a common language may improve care.

As discussed above, coding and classification of health records can help in the organisation of information for communication and also in its collection for computer processing. However, at present relatively little information in health records is coded or in a structured format (Table 4). In mental health care most clinical information and medic news are in a free-text format. Table 4 Structure and type of information in typical health records The NHS is currently evaluating a semi-structured system for communications and possibly for health records (American Hospital Association, 2002).

Its advantage is that communications are structured to provide information in a standard language, medic news without the limitations of hierarchical and other classifications.

A template of headings for communicating patient information has been developed on the basis of previous evaluations (NHS Information Authority, 2000), and this is being assessed in everyday practice in a medic news of medic news specialities. The advantage of the semi-structured system medic news that its framework should improve the consistency of content of clinical communications.

Additionally, the structure allows free text, so that the richness and detail of the consultation and planning relating to the patient are not lost. The approach currently being taken is to use headings that will form part of a multi-professional clinical information standard (Box 3). Regarding authoring and reading health records: a structure increases the chance medic news errorc subjective, objective, assessment and plan are four types of data describedd history, observations, assessment and plan are four types of data describede identifiers, patient findings, hypotheses, actions and modifiers are categories of clinical data.

Regarding teamworking: a structures are needed for key clinical communicationsb medic news information in shared health records is written as free textd semi-structured communications may combine the benefits of structured information and free-text informatione the draft standard for communicating patient medic news contains health characteristics.

With respect to communication and health records: a SNOMED has its medic news in pathologyb Clinical Terms (Read Codes) were initially used in primary careTable 1 Categories of clinical data (after Medic news, 1994)Fig. Type Research Article Information Advances in Psychiatric TreatmentVolume 8Issue medic newsMay 2002pp. Standards governing organisation of information The way in which information is organised affects the meaning and the quality of communications.

Authoring and reading health records Efficient record-keeping is essential for good clinical practice and service delivery. Table 1 Categories of clinical data (after Reference WyattWyatt, 1994) A common language: classification and coding In the authoring of health records, we should use common standards for both recording and communicating information.

Box 1 SNOMED axes (after Reference RothwellRothwell, 1995) Medic news 2 Systems for different classification purposes Table 3 Medic news of classifications Problems with coding and medic news structured records The current classification systems substantially improve the organisation of medic news for communication, but we should medic news be aware of the purpose for which they were intended. Electronic patient records and electronic health bandol roche redonne Patient records are key to the delivery of quality medic news care.

Box 2 Main components of the six levels of the electronic patient record Organising information for medic news within and between teams The development of electronic records and communications will further highlight the need for common standards of information organisation for communicating and teamworking. Regarding authoring and reading health records: a structure increases Dasetta (Norethindrone/Ethinyl Estradiol Tablets)- FDA chance of error b medic news have become increasingly task-oriented c subjective, objective, assessment and plan are four types of data described d history, observations, assessment and plan are four types of data described e identifiers, patient findings, hypotheses, actions medic news modifiers are categories of clinical data.

Regarding teamworking: a structures are needed for Erythromycin Ethylsuccinate (EryPed)- Multum clinical communications b most information in shared health records is written as free text c separate records aid clinical communication d semi-structured communications may combine the benefits of structured information and free-text information e the draft standard for communicating patient information contains health characteristics.

With respect medic news communication and health records: a SNOMED has its origins in pathology b Clinical Terms (Read Codes) were initially used in primary care c Clinical Terms contain qualifiers d the sharing of information systems improves record-keeping e structured communication can only be used electronically.

Google Scholar Clinical Systems Group (1998) Improving Clinical Communications. Google Scholar Cote, R. Northfield, IL: College of American Pathologists. Google ScholarDe Moor, G. Google Scholar Department of Medic news (1998) Medic news for Health. Medic news ScholarPubMed Fienstein, A.

Google Scholar Johnston, M. A critical appraisal of research. CrossRefGoogle ScholarNHS Executive (1999) Learning to Manage Health Information. Google Scholar NHS Information Authority (2000) Towards an Information Standard for Organising Clinical Communications. London: NHS Information Authority. Google ScholarPubMed Rothwell, D. Google ScholarPubMed Medic news, P. In Proceedings of the Symposium on Computer Applications in Medical Care, pp.

Bethesda, MD: American Medical Informatics Association. Google Scholar Tange, H. Towards a model for flexible access to free text medical data. Google Scholar Wyatt, J.

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