ABSTRACT
Health care professionals have decided to go paperless and they want to develop procedures to make sure they record all the information he/she need. They have identified all the places and people that give their information and the general practitioner need to decide how he/she is going to deal with all that data. When the primary care team started to think about what information they needed to know from all the people and places that gave them data they realized that they did not know what was being recorded. The primary care team decided that they needed recording guidelines for the practice. They also agreed that wherever possible the clinicians would record the data during consultations. Data entry by clinicians at the point of care is recommended wherever possible. Generally practices deal with these issues by developing procedures that involve the data being entered into the practice computer system by clerical staff.
