The figure above together with reflection also shows the limitations of the record forms. A great deal of sensitive information is retained in the cognitive record, perhaps even more so since patient access to records. Self awareness is vital to maintain our social models, to ensure objective balance, and accountability. Social impressions often survive, while pure matters of fact about people do not, especially those that are not recorded or reinforced. If recorded on paper it may be incomplete, inaccessible or redundant for immediate purposes.
Audit centred on machine records remains a young science.
Time to train. Concerns expressed by several professional bodies including the BMA, culminated in The Caldicott Committee recommending that organisations in the UK adopt Caldicott Guardians to monitor and check the flow of information and matters of confidentiality. Clinical Governance Support Service, Info Sheet 13, Clinical Notes. Plans and Situated Actions,CUP,p.78.