In English: Facilitating clinical documentation at the point of care
It’s about time we improve our way of recording information, so that it’s more beneficial to us and to our patients. That’s why more and more Dutch hospitals are working together on the project: Facilitating clinical documentation at the point of care. Watch our animation film for a short explanation.
If we no longer consider healthcare information as our personal notes but start recording it unambiguously – which we refer to as ‘Facilitating clinical documentation at the point of care’ - then we can easily reuse this information by means of a standardised language based on international standards. We record healthcare information only once, and we can directly hand over the data to colleagues who are involved in the treatment. Patients have access to their files and can add relevant information. As all the information is recorded unambiguously at the point of care, it becomes easier for us as healthcare professionals to supply the required information for quality assurance, research and to other parties. We call this ‘multiple use’.
The healthcare information travels along with the patient, over the boundaries of our healthcare institutions. This is only possible with systems that speak the same language ‘under the hood’ (so to speak) and if we use these systems in the correct, unambiguous way. This entails a new way of recording information. This will take some getting used to.