Clinical governance and clinical documentation: still a long way to go?

Abstract

Maintaining good standards of clinical documentation remains a problem in the health service despite continued and consistent advice from protection organisations and professional bodies over many years. This article discusses some of the issues that arise from poor quality note keeping and the need for improvement and the establishment of basic minimum standards for all health records. Requirements are now being placed on NHS bodies to ensure that effective and robust systems are in place to ensure that record management meets Controls Assurance Standards and CNST standards. This article stresses the need to put the current house in order before we lose any opportunities to influence those aspects of electronic systems where appropriate risk management should help reduce the potential for documentation error.