An appraisal of health records and information management standards and influencing factors

Abstract

The healthcare record refers to all information collected, processed and held in both manual and electronic formats pertaining to the patient and patient care. It includes demographics, clinical data, images, unique identification, investigation, samples, correspondences and communications relating to the patient and his/her care1. The patient’s health record serves many functions but their primary purpose is to support patient care1. Every time the patient moves from one place to another, information about his condition is registered2. Critical patient information is often not available when and where needed and this makes the whole process take much longer.