The clinical record has many features, the most essential of which are listed in Box 1. It gives together historical and contemporaneous information from several sources, recorded by many individuals from many organizations. It is also used progressively in the evaluation of professional proficiency: review of case notes and other records is a recommended method for evaluating key competencies. These requirements are mutually interdependent. For illustration, a case history which is fit for purpose as an operating document for day-to-day recording of patient care is more probably to generate useful information for research.The uses of the clinical record
• To act as a working record for day-today documenting of patient care.
• To store a date account of the patient’s life, illnesses, its context and who did what and to what effect.
• To allow the clinician to connect with him- or herself.....................read more at>>>The uses of Electronic record-keeping
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