Clin Med
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Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation are unlikely to be realised. ⋯ The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.
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Developments over the last decade in legislation and professional guidance on confidentiality and medical research in the UK are reviewed. Despite the General Medical Council's guidance, and recent changes to the common law on confidentiality in England and Wales, confusion remains about what is lawful and professionally acceptable in the handling of identifiable data. The GMC has contributed to this confusion. ⋯ Public consensus is required on an acceptable balance between the citizen's right to privacy and the responsibility of society--to which all citizens belong--to protect the public health. The Government should survey public opinion, inform NHS patients better, initiate wide public debate, and legislate to protect both citizens' rights and medical research that is demonstrably in the public interest. Registration of cancer and communicable diseases should become statutory.