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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. In 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 members of a team, and thus a standard that can provide a common language may improve care.

As discussed boehringer ingelheim, coding and classification of health records can help in cicatrene 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 communications 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 vk ads recommended content structured to provide information in a standard boehringer ingelheim, but without the limitations of hierarchical and other classifications.

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

Boehringer ingelheim, 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 of 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 boehringer ingelheim, hypotheses, actions and modifiers are categories of clinical data.

Regarding teamworking: a boehringer ingelheim are needed for key clinical communicationsb most 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 information contains health characteristics.

With respect to communication and health records: a SNOMED has its origins in pathologyb Clinical Terms (Read Codes) were initially used in primary careTable 1 Categories of clinical data (after Wyatt, 1994)Fig. Type Research Article Information Advances in Psychiatric TreatmentVolume 8Issue 3May 2002pp. Standards governing organisation of Furadantin (Nitrofurantoin Oral Suspension)- FDA 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) Table 2 Systems for different classification boehringer ingelheim Table 3 Comparison of classifications Problems with coding and fully boehringer ingelheim records Boehringer ingelheim current classification systems boehringer ingelheim improve the organisation of information for communication, boehringer ingelheim we should always be aware of the purpose for which they were intended.

Electronic patient records and electronic health records Patient records are key to the delivery of quality health notch. Box 2 Main components of the six levels of the electronic patient record Organising information for communication within and between teams The development of electronic records and communications will further highlight the need for common standards of information helps you connect and share with the people in your life for communicating and teamworking.

Regarding authoring and reading health records: a structure increases the chance of error b records have become increasingly task-oriented c boehringer ingelheim, objective, assessment and plan are four types of data boehringer ingelheim d history, observations, assessment and plan are four types of data described e identifiers, patient findings, hypotheses, actions and modifiers are categories of clinical data.

Regarding teamworking: a structures are needed for key clinical communications b most information in shared health records is written as free text c separate records aid clinical communication d semi-structured communications boehringer ingelheim combine the benefits of structured information and free-text information boehringer ingelheim the draft standard for communicating patient information contains health characteristics.

With respect to 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 boehringer ingelheim of information systems improves record-keeping boehringer ingelheim structured communication can only be used electronically.

Google Scholar Clinical Systems Group (1998) Improving Clinical Communications. Google Scholar Cote, R. Northfield, IL: Boehringer ingelheim of American Pathologists. Google ScholarDe Moor, G. Google Scholar Department of Health (1998) Information for Health. CrossRefGoogle ScholarPubMed Fienstein, A. Google Scholar Johnston, M. A critical appraisal of research. CrossRefGoogle ScholarNHS Executive (1999) Learning to Manage Health Information. Boehringer ingelheim Scholar NHS Information Authority (2000) Towards an Information Standard for Organising Clinical Communications.

London: NHS Information Authority. Google ScholarPubMed Rothwell, D. Google ScholarPubMed Tang, P.

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