Improving the accessibility and quality of clinical and patient information in the patient’s medical notes

Abstract

Objectives To improve the accessibility and quality of information in the medical notes including: the patient’s general and homeopathic history at a first consultation, the rationale for the homeopathic prescription, the evaluation of the prescription, the evaluation of the progress of the patient at follow-up visits, and the usage of conventional medication. Information needs to be accessed easily from the medical notes and needs to be of sufficient quality to be useful to clinical staff and others. This information is one source for measuring quality in clinical audit, which is an important part of the new concept of Clinical Governance which is now a requirement for British public sector hospitals. Various doctors had highlighted the difficulty in finding information easily from the notes, particularly if the patient was new to them.