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1 results

  • Chapter 3 - Note Keeping in the Digital Age

  • Edited by Rob Waller, NHS Lothian, Omer S. Moghraby, South London & Maudsley NHS Foundation Trust, Mark Lovell, Esk and Wear Valleys NHS Foundation Trust
  • Book:
    Digital Mental Health
    Published online:
    23 November 2023
    Print publication:
    07 December 2023, pp 41-49

  • Summary

    The mental health clinical records has evolved through a long journey and its structure has been stable for decades. Until the scientific basis of mental disorders is understood at an aetiological level, the current format of case notes needs to be replicated in EHRs but the use of free text needs to be curtailed. Better design of EHRs and increased use of standard clinical terms can enhance the ability to code information in the EHRs. This in turn can support adoption of technical solutions that better manage workflows and provide clinical decision support to reduce variation in care and ensure higher quality of care. Professional bodies need to develop guidance for their members and the competencies impacting on use of EHRs need to be part of training curricula and evaluations.