The standardisation of hospital medical records / report of the sub-committee.
- Great Britain. Standing Medical Advisory Committee
- Date:
- 1965
Licence: Public Domain Mark
Credit: The standardisation of hospital medical records / report of the sub-committee. Source: Wellcome Collection.
25/68 (page 19)
![54. In considering the actual standard layout of the headings we had to take into account the fact that both manual and mechanical systems of reproducing patient identification details were in use and that there was quite a wide range of mechanical systems. (We refer in more detail to mechanical systems below). We decided that the minimum patient identification details for any form were full name and unit number. These take up little space and for manual recording the box for them need only be small. Mechanical recording plates however commonly contain other details which it is not economic to mask out and there- fore we decided that the box should be large enough to take the normal size of mechanically recorded impression or label. For manual recording the words ‘name’ and ‘unit number’ need to be printed in the box and these could not fit the details printed on the form by a mechanical system. We found however that the printing could be faint enough and small enough not to conflict with any mechanicaily recorded overprinting. Our examination of records in use showed that the most common place for the patient identification box was at the top right hand corner of the form and we think that this is the right place. The unit number should be at the top right hand corner of this box. The title of the form should be at the top of the form and the form number should be at the top left hand corner. The space to the left of the patient identification box we suggest should be used for hospital identification particulars. We noted that in a number of hospitals it was the practice to print the consultant’s name in very large letters, dominating all other identification particulars. We can see no practical value in this and we deprecate it. The standard layout we recommend is illus- trated in figure 1. (ii) Mechanical systems for registration and documentation 55. Although the use of mechanical registration systems presupposes some degree of standardisation, if only of sizes of spaces, we have indicated above that the adoption of any particular system of registration, manual or mechanical may require the acceptance of a standardised design for headings. We however went into the use of mechanical] systems in some detail to determine if a specific recom- mendation on their use was called for. (See paragraph 58). 56. The process of writing the identification particulars of a patient on the various documents used during the period of a patient’s treatment in hospital either as an in-patient or as an out-patient is a tiresome business. It involves clerks and nurses in repetitive tasks and can irritate the patient if he is asked for the same information tirne and time again. There is a risk of error, particularly im recording the patient’s unit number, on every occasion that the details are written down. Inevitably in a busy department some of the writing is hurried and far from clear, and there is a temptation to miss out details. 57. All these disadvantages can be removed by a system in which the identi- fication details are reproduced from a master prepared on the initial registration of the patient. There are at present in use three main types of equipment. One uses a metal or plastic plate embossed with the identification details as the master. Another uses a silk stencil on which the details are typed, and the third uses a paper master which can be used with a spirit duplicator. In each of these systems part of the information on the master can be masked out to produce a limited range of information needed on some documents. Each of the systems](https://iiif.wellcomecollection.org/image/b32174573_0025.jp2/full/800%2C/0/default.jpg)
