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Chapter 3 - Note Keeping in the Digital Age

Making Good Use of Electronic Records Systems

Published online by Cambridge University Press:  23 November 2023

By
Hashim Reza
Edited by
Rob Waller ,
Omer S. Moghraby  and
Mark Lovell
Rob Waller
Affiliation:
NHS Lothian
Omer S. Moghraby
Affiliation:
South London & Maudsley NHS Foundation Trust
Mark Lovell
Affiliation:
Esk and Wear Valleys NHS Foundation Trust
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Summary

The mental health clinical records has evolved through a long journey and its structure has been stable for decades. Until the scientific basis of mental disorders is understood at an aetiological level, the current format of case notes needs to be replicated in EHRs but the use of free text needs to be curtailed. Better design of EHRs and increased use of standard clinical terms can enhance the ability to code information in the EHRs. This in turn can support adoption of technical solutions that better manage workflows and provide clinical decision support to reduce variation in care and ensure higher quality of care. Professional bodies need to develop guidance for their members and the competencies impacting on use of EHRs need to be part of training curricula and evaluations.

Keywords

EHRECREPRdigital clinical recordnote keepingclinical records,
Type
Chapter
Information
Digital Mental Health
From Theory to Practice
 , pp. 41 - 49
Publisher: Cambridge University Press
Print publication year: 2023

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References

Further reading

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Turner, J., Hayward, R., Angel, K. et al. The history of mental health services in modern England: practitioner memories and the direction of future research. Med. Hist. 2015;59(4): 599–624.Google Scholar

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