Healthcare Data Management, Record Keeping, and Legal Responsibilities

Vocabulary practice flashcards covering digital tools, healthcare reporting systems, communication formats, record keeping standards, legal responsibilities, and medical abbreviations.

Artificial Intelligence (AI)

A digital tool used in healthcare to analyse large data sets (such as bioinformatics or diagnostic patterns) and apply algorithms to interpret medical images from CT scans or radiography.

Medical Devices

Instruments, apparatus, appliance software, or material intended for human use to perform a medical purpose such as diagnosing, monitoring, and treatment (e.g., blood pressure monitors, glucose monitors, pacemakers).

Cloud-Based Systems

Systems that enable secure access to electronic health records (EHRs) from multiple locations, allowing safe storage of medical data and access for sharing among authorised healthcare professionals.

Digital Information Management Systems

Systems that create digital audit trails to track how data is used and identify who accessed a patient's records, helping maintain patient confidentiality.

Data Visual Tools

Tools that present complex healthcare data clearly using charts, dashboards, or infographics to track patient health, manage in-house hospital processes, and help eliminate diagnostic human error.

Electronic Paper Records (EPR)

Digital charts used in clinics and hospitals to track daily notes, tests, and care plans.

Shared Care Records (ShCR)

Regional records that link GP files, mental health data, and care needs across different services.

Summary Care Record (SCR)

A fast national summary holding key patient details such as allergies and current medicines.

NHS Spine

A national infrastructure that links local clinical records to unique NHS numbers.

Oral Reports

A communication format used in handover meetings, ward rounds, and emergency updates, offering immediate feedback but lacking a permanent auditable record.

Written Reports

Structured documentation used in discharge summaries, care plans, and referral letters that provides a permanent, auditable record.

Clinical Audit

A systematic review process to determine whether healthcare is being provided in line with standards, highlighting areas where a service performs well and where improvements are needed.

Duty of Care

A mandatory legal requirement applying as soon as an individual receives care or treatment, obligating workers to promote wellbeing and keep people safe from harm, abuse, and injury.

Duty of Candour

A legal and professional requirement for health and care providers to be open, honest, and transparent with service users and families when things go wrong by explaining what happened, apologizing, and explaining lessons learned.

Accountability

Being responsible for one's actions and inactions in professional healthcare practice.

Safeguarding

The duty to protect vulnerable individuals from harm or abuse and escalate concerns (such as unexplained bruises, withdrawal, self-harm, or neglect) to a senior nurse or safeguarding officer.

Whistleblowing

When a worker reports serious wrongdoings, risks, or unsafe practices (such as abuse, neglect, or broken laws) that affect vulnerable people in order to protect public safety.

Radicalisation

The process through which a vulnerable individual is groomed or manipulated to adopt extreme political, social, or religious views.

Contemporaneous Recording

The practice of documenting healthcare interactions and care at the time they occur, or explicitly dating and identifying late entries if written in retrospect.

Caldicott Principles

Guidelines governing the sharing of patient-identifiable information, which include using NHS numbers instead of patient names where possible and seeking patient consent.

PRN

Abbreviation for Pro Re Nata, meaning medication to be taken as needed.

MAR

Medical Administration Record; documentation used to record medications administered to a patient.

DNACPR

Do Not Attempt Cardiopulmonary Resuscitation; an advance clinical decision regarding resuscitation efforts.

MUST

Malnutrition Universal Screening Tool; a clinical assessment tool used to identify individuals at risk of malnutrition.

NEWS 2

National Early Warning Score 2; a track-and-trigger system used to determine the degree of illness in an adult patient.

PEWS

Pediatric Early Warning Score; a scoring system used to monitor and detect early clinical deterioration in children.