The purpose of the case record

The most important function of the case record is to allow information to be shared amongst the health professionals involved in a patient's care. Many hospitals now use multi-disciplinary or unitary medical case records. The alternative is that each different profession documents information in its own 'specialist' notes. One patient can thus end up with separate sets of notes for nursing, physiotherapy, occupational therapy and social work as well as a medical case record, with much unnecessary duplication of information between them. The purpose of raultidisciplinary notes is to avoid this duplication and to encourage a shared, holistic approach to care.

Within a case record, junior medical staff record their initial findings and plan of management. More senior medical staff may add comments regarding their own findings, and the proposed investigations and management. Records should be accurate, legible and clearly signed. This is especially so in specialities where doctors work a shift system. Should a patient present with a different problem in the future, it can be useful to compare the new findings with those found al the patient's earlier presentation. Other functions of the case record are shown in Table 9.1. It should he remembered that the case record is confidential and details must not be divulged to anyone who is not involved in the patient's care. The case record is a legal document which may be used in a court of law.

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