By default, many discussions and specifications of electronic health records or integrated care records often conceptualise the record as a passive information repository. This paper presents data from a case study of work in a medical unit in a major metropolitan hospital. It shows how the clinicians tailored, re-presented and augmented clinical information to support their own roles in the de...

Methods Setting: A quantitative retrospective audit was carried out over 4 months. The medical charts and dietetic record cards of patients with raised blood glucose levels (defined as ≥8mmol/L) who were receiving enteral nutrition in Beaumont Hospital were collected by the department of Nutrition and Dietetics during the months of May to August. Patients: Medical charts and dietetic record car...

Benchmarking is having an increasing impact on the health information management (HIM) profession. With the current focus in healthcare on competition and outcomes, the challenge for managers of MRDs (predominantly HIMs) lies in proving that what they do, and the way they do it, achieves results which benefit the organisation and, ultimately, the patient or client. The Medical Record Department...