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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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