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RECORDS: Health and Social Care

Keywords: Records, Cognitive record, Manual written record, Computer based (distributed) record, Security

Citing this page:
Jones, P. (2005) Hodges' Health Career - Care Domains - Model: Records,
<>, Accessed

threeIntroduction: Record Keeping [under revision]

In addition to the dictates of Finagle's Law let us remind ourselves of why we need records? The reasons are listed in professional guidance literature, unit policy and standards standards and notices. According to The Maudsley Handbook of Practical Psychiatry (3rd Edition) and the UKCC's Guidelines for Records and Record Keeping (1998) cited by CRU (1999) we need records:

information overload
  • to capture initial patient information at time of referral, some of which may already be on file if patient is known to the service
  • to record the initial assessment and diagnosis of the patient's condition
  • to form a basis for planning the patient's care and treatment, getting feedback on their progress and suggesting action for prevention and health promotion
  • to assist continuity of care amongst health professionals and provide written evidence that a service has been delivered
  • to meet legal requirements
  • to meet professional or statutory requirements
  • to provide information for clinical management, resource management (such as staffing levels), self-evaluation, clinical audit, quality assurance research and evaluation.

Poor record keeping:

  • undermines patient care
  • makes health professionals vulnerable to legal and professional problems
  • increases workloads
Paper files in storage

The introduction posed a (very) hypothetical question comparing health transactions with those of the commercial world. This presupposes that health care provision occurs in an economic vacuum, but of course nothing could be further from the truth. Health care delivery involves finance, as our politicians constantly remind us.

In the UK the DoH has a code of practice for records management in the NHS that is reviewed periodically.

Problems of scale and scope

Although financial transactions are more readily apprehended, in that we have all witnessed, or taken part in transactions involving monies (cheques, etc.) for goods; health transactions are a different matter. As noted previously health transactions potentially covers a variety of activities, actions and promises for example:

  • counselling;
  • advice giving;
  • education - (ante-natal class);
  • a treatment - (injection);
  • treatment delivery (hip replacement);
  • advocacy;
  • consultation (psychiatric out-patient clinic).

As this brief list shows (does it?) granularity is a problem in defining transactions. Granularity in terms of the level of description and detail. Overall, a consultation could be thought of as a compound transaction, being comprised of smaller transactions, which are not necessarily health related. We could explode the consultation into smaller units, which given the social nature of health would be conversational. From a linguistic point of view each sentence and part sentence denotes part of a verbal health transaction. Closer examination of the sentences might reveal adjacency pairs (Suchman, 1987), nested questions which are responded to once an avenue of questioning is completed.

For our purposes here - tracing what health transactions might be - we are not interested in the minutia of speech content and structure, but on those parts of verbal interactions that have significance in health contexts. Frequently, however, these so-called minutia are a very important part of the process of completing a health transaction (or other human activity). Generally, interest lies in the outcome and the measurement of the outcome. It is these that are usually recorded.

If the minutiea of a particular health transaction were that important we might record and retain a transcript (or some other form) of the whole consultation verbatim. Where risk is an issue to the patient (self-harm), a child or older person (abuse) or the public at large (violence to others), seemingly smaller details assume greater significance. So what is captured, because that may tell us more about health transactions. One way to describe the health record is via purpose. The main methods to record health transactions are:




Computer screen static

Operational types of record: Idealised, Paper Record, Mental Record, CBR & D-CBR

Using the above methods, the figure below shows a patient-nurse interaction that results in information production and revision. Some of this information is written into the paper record. Some is retained by the nurse in memory - what might be termed the cognitive or mental record. This particular record deteriorates quickly in its accuracy; one reason for use of paper records. Both the nurse and patient may contribute directly to a computer based (electronic) record. Sometimes (all too often?) data entry to the computer may be via a paper record. In such cases unnecessary duplication of effort may occur.

Click above image to expand

In mental health care (and indeed elsewhere) the importance of the cognitive record is stressed. It controls - in tandem with idealised forms - what is recorded on paper or machine. The abstract idealised record exists via health (and social welfare) policy (in the UK the Care Programme Approach is a prime example); standards; years of training, models of nursing and the nursing process. Audit is centred on a comparison of idealised with paper record forms, (and cognitive too - do staff know the policies?).

The figure above together with reflection also shows the limitations of the record forms. A great deal of sensitive information is retained in the cognitive record, perhaps even more so since patient access to records. Self awareness is vital to maintain our social models, to ensure objective balance, and accountability. Social impressions often survive, while pure matters of fact about people do not, especially those that are not recorded or reinforced.

Since (as managers know!) time is short, the obvious method of reinforcement is verbal, much factual information is retained in memory. If recorded on paper it may be incomplete, inaccessible or redundant for immediate purposes. Social skills (hence implied knowledge) are vital tools in dealing with people at risk. Raw factual information - age, sex, last admission, Consultant - is insufficient clinically even if complete. Audit centred on machine records remains a young science. Without an idealised form of the computer based nursing (health) record, we are like awkward adolescents.

A diagram using the HCM to represent the above discussion is supplied here...


Click above image to expand

A review of the pros and cons of each of the three record types follows:

pros and cons
cognitive record written record computer based record
cognitive typewriter pcb

The arrival of the computer based record form especially in its distributed, networked form poses several concerns for health care staff:

  • Control of the accessibility of information.
  • Personal accountability.
  • Recognition that the clinical and social welfare workers from organisations with different management structures/funding need to share information.
  • Time to train.

Concerns expressed by several professional bodies including the BMA, culminated in The Caldicott Committee recommending that organisations in the UK adopt Caldicott Guardians to monitor and check the flow of information and matters of confidentiality. It is the contents of records however defined or described that are invaluable. Following the Data Protection Act and its revisions, January 2005 sees the arrival of the Freedom of Information Act. Informatics and policy bear

Informatics & Records: The Policy Context

A review of the programmes undertaken in the past 10-15 years reveals the importance of a unique identifier - the NHS Number - and master patient index. Amid the formation of new Trusts what has frequently happened is the inheritance of Patient Administration Systems (PAS) from different suppliers, or even with the same supplier different configurations, facilities and user base. For the new organisation this becomes a critical issue as the Health Care Commission assesses Trusts against service criteria. It is difficult to have true integrated working - health and social services without an IT infrastructure and buildings. That is before we get to actual electronic patient levels.

Current NHS informatics policy is built upon the 1998 National Health Information Strategy: Information for Health. This was followed by an update Building the Information Core (2000). Within the national strategy is a mental health information strategy, that is further specialised in the Information Strategy for Older People. The underlying requirement is to translate the vision outlined in the informatics policies and the NHS Plan especially the National Service Frameworks (NSF).

It is worth relating the frequent preoccupation with process in informatics to h2cm and policy. Positively, on the mechanistic side of h2cm, policy and processes are more tightly aligned. To what extent this is intentional - a direct outcome of policy, or an emergent property of a complex organisation is a matter of debate.

The right-hand h2cm domains contrasts sharply however, with what is often seen as a vacuum in the others. IT project after IT project the need for engagement with users and communications are stressed. These conclusions are reached and preached as outcomes from inquiries as to why this project and that failed. There are a host of shorthand heuristics and folk theories that posit techniques to reduce the impact of problems. What can the 4Ps provide?

People need to have a sense of purpose. Why are they following particular processes? To what end? How do the processes and policy relate to work practices? Are they meaningful to all staff groups? Or only coherent to management and administrators?

Processes and policies must be relevant to individual workers, who must internalise these to inform their own beliefs, attitudes and motivations in their day-to-day work.

Policies in the past rarely needed to be consulted, viewed perjoratively by many staff as the paper exercise. Now two factors help bridge the distance between practice and policy: information and information and communications technology - with emphasis on communications. Policy is a paper exercise if they are not accessible to staff and of course now intranets can make policies available to the workforce, locally, nationally and internationally and even at home.

National Programme for IT

From 2004 onwards the NHS National Programme for IT [NPfIT] will become the operational, tactical and strategic focus for all stakeholders. In April 2005 the NHS Information Authority will become a Strategic Health Authority adopting the title NPfIT. I say 2004 because this is when NPfIT made a difference for me and my former colleagues as I commenced a secondment within our organisation on the local roll-out of part of NPfIT: the NHS Care Record Service. Whatever the media may conclude about health care IT there are signs for those who look of evolution in action - a decade is a long time in IT. Like a jigsaw coming together, individual pieces shifting as it is realised where there is a fit. The Electronic Patient Record levels a former benchmark are still apparent in the NPfIT timeline. It is acknowledged that the first three levels are administrative, with eventual arrival at a person (patient and carer) centred electronic health record.

© Peter Jones 2005


The Caldicott Committee (1997) Report on the Review of Patient-Identifiable Information, London Department of Health.

College Research Unit (1999) Clinical Governance Support Service, Info Sheet 13, Clinical Notes.

HC(90)23/LASSL(90)11. Department of Health, London, UK.

Suchman, L. (1987) Plans and Situated Actions, CUP, p.78.

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 !  See also

Informatics: Defining Data, Information Theory

:Introduction to Coding & Classification

:Nursing a Language

LINKS II: Informatics

LINKS IV: Informatics Companies