PRINCIPLES OF GOOD RECORD KEEPING

Principles of Good Record Keeping

Principles of Good Record Keeping

Introduction

Keeping record is one of the key factors that help the business to be successful. Organization should realize the importance of keeping record of their employees as it is vital to the success of any business. Accurate and up-to-date records are one of the essential business tools. People run their own business and invest so much time in order to run their business but fail to realize that they should maintain good documentation. In order to get the maximum return, the owner of the business should maintain good records. (Carpenter, 2007, 328)

Organizations should keep a track of every activity of their business. They should develop proper record system which needs to be accurate, simple, easy to use and reliable. Good record keeping helps to achieve the financial targets of the business. It also assist is making future decisions of the business. It should be monitor on a regular basis. Every department should maintain their departmental records as it will help to have a look on the department's performance. It also helps in getting access to those areas where problems could arise and help them to provide those means to sort out those problems.

There is an increased awareness of record keeping in health and care sector. Healthcare sector do the record keeping due to the public disclosures, enquiries and media reports. This has enhanced the need to evaluate their practice and those of their employing body. The patient should be properly observed and his or her record must need to be maintained as much decision would be made based on reports from patient's observation and documentation. Every healthcare facility has different record keeping formats and systems of documentation. Local and national policies set those record keeping standards.

This paper will discuss the purpose, principles, legal implications and legislation of accurate record keeping in healthcare sector. The purpose of healthcare records is to facilitate: communication between healthcare professionals and clients; care planning; quality assurance of care; educational tools for professional development; legal documentation for court cases; and healthcare analysis to monitor trends in services.

Types of Records that are kept in Healthcare Sector

There are two types of records that are maintained in healthcare sector i.e., EMR (Electronic Medical Records or Electronic Health Records), and PHRs, Personal Health Records. Medical practitioners keep these records in order to know about their work with patients. They are relatively new form of recording but they are very beneficial. (Marieke, 2011, 20)

1. EMR This type of record maintenance system helps the doctors, insurance companies as well as healthcare facilities to know the medical record of the patient. This is a computerized record system.

2. PHR

This record system helps the patient to know about his medical record. Using the personal health record provides the patient an opportunity to have complete knowledge about his or her disease.

These record systems should be used in every healthcare sector.

Responsibility and Accountability for Record Keeping in the Healthcare Sector

The record of the ...