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WHAT CONSTITUTES A CLINICAL RECORD OR DOCUMENT IN HEALTH CARE?

 

Clinical records include a wide variety of documents generated on, or on behalf of, all the health professionals involved in patient care.

 

This includes:

• Handwritten clinical notes
• Computerised/electronic clinical records
• Emails
• Scanned records
• Text messages (both outgoing from the NHS/professional and incoming from patients)
• Correspondence between health professionals
• Laboratory results
• X-ray films and other imaging records
• Photographs
• Videos and audio recordings
• Printouts from monitoring equipment, particularly in anaesthesia and obstetrics, A&E and ICU
• Consent forms

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