Managing information

Abstract

Information management is an essential component in risk management and clinical governance. In neonatology, the areas related to information management are: (1) clinical records; (2) clinical information databases; (3) evidence-based practice; and (4) audit and outcome measures. Record keeping is an integral part of clinical practice and medical records should be an accurate account of clinical details. Clinical information is used for many purposes other than patient-care documentation. Evidence-based medicine is the use of current best evidence to make decisions about the care of individual patients. Benchmarking using illness severity adjustment is a crucial tool for studying variations in outcomes. Neonatal intensive care is well suited to such benchmarking but further development of standardised audit tools - both for interventions and for outcome measures - are required.

Improvement in Documentation Using an Electronic Checklist for Shoulder Dystocia Deliveries

“…Documentation that is thorough may be seen as evidence of high-quality care and a skilled and safe healthcare provider, whereas an incomplete record may give the perception of wider problems with an individual's practice. 12 Because of this, we feel that the use of an electronic checklist tool such as the one we have described may be a reasonable option for effectively communicating the event so that it is legible, factual, and timely.…”