ABSTRACT
The use of electronic patient records has been a health service vision for the past 30 to 40 years. The majority of general practitioners are information and communication technology literate, using computers for clinical care recording and for business information. Some allied health professions (AHP) have access to information technology (IT) systems which focus on clinical activity, allowing them to record contact information – appointments, attendances and demographics. All AHPs require information governance competencies that demonstrate the knowledge, skills and understanding required for the competent handling of healthcare related information to recognised ethical, legal and quality standards. IT supports the real requirements of clinical records which is information capture and sharing. Identifying the information needs before specifying a system will make it easier for IT to find a solution that meets clinical recording needs. SNOMED Clinical Terms are a comprehensive clinical terminology that provides clinical content and expressivity for clinical documentation and reporting.
