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The recommendations are contained in a report from Robert Francis into systemic patient neglect at the trust between 2005 and 2009.
Robert Francis QC said: “Improvements are needed in the core information systems for the collection of data about patients, both to support their individual treatment and the accurate collation of information for statistical purposes.”
There is a need for all to accept common information practices and to feed performance information into shared databases for monitoring purposes, it added.
“Patients need to be granted user-friendly, real-time and retrospective access to read their records, and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible, the summary care record should be made accessible in this way,” stated one of the recommendations.
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Systems should be designed to include prompts and defaults where these will contribute to safe and effective care, and to enable accurate recording of information on first entry, it said. They should also include a facility to alert supervisors where actions which might be expected have not occurred, or where likely inaccuracies have been entered.
The systems must be designed by healthcare professionals in partnership with patient groups to secure maximum professional and patient engagement in ensuring accuracy, utility and relevance, both to the needs of the individual patients and collective professional, managerial and regulatory requirements, it said.
Trust boards should also provide full and accurate information about their compliance or non-compliance, with the data made available on each trust’s website, and should be audited, it said.