Health records serve two main functions - primary and secondary. The primary function is to record important clinical information for healthcare professionals involved in a patient's care, such as treatments, allergies, medications, test results, and personal details. The secondary function is to use anonymized record data to improve public health services, track disease spread and risk factors, and conduct clinical research on treatment effectiveness. Records take many forms, both paper and electronic, and include notes from appointments, hospital admission and discharge records, test results, x-rays, and images. Employers and those in control of premises have a legal duty under RIDDOR to record and report work-related injuries, diseases, and incidents.

1. Importance of recording and
reporting

2. Recording
Health records play an important role in modern healthcare.
They have two main functions, which are described as either
primary or secondary.

3. Primary function of health records
:
The primary function of healthcare records is to record
important clinical information, which may need to be
accessed by the healthcare professionals involved in your
care.

4. Information containedin health records includes
 The treatments you have received,
 Whether you have any allergies,
 Whether you're currently taking medication,
 Whether you have previously had any adverse reactions to
certain medications,
 Whether you have any chronic (long-lasting) health conditions,
such as diabetes or asthma,
 The results of any health tests you have had, such as blood
pressure tests,
 Any lifestyle information that may be clinically relevant, such
as whether you smoke, and
 Personal information, such as your age and address.

5. Secondary function of health records
 Health records can be used to improve public health and
the services provided by the NHS, such as treatments for
cancer or diabetes. Health records can also be used:
 To determine how well a particular hospital or specialist
unit is performing,
 To track the spread of, or risk factors for, a particular
disease (epidemiology), and
 In clinical research, to determine whether certain
treatments are more effective than others.

6. Types of health record
Health records take many forms and can be on paper or electronic.
Different types of health record include:
 Consultation notes, which your GP takes during an appointment,
 Hospital admission records, including the reason you were admitted to
hospital,
 The treatment you will receive and any other relevant clinical and
personal information,
 Hospital discharge records, which will include the results of treatment
and whether any follow-up appointments or care are required,
 Test results,
 X-rays,
 Photographs and image slides, such as those produced by a magnetic
resonance imaging (MRI) or computerised tomography (CT) scanner.

7. Why record andreport?
 Recording and reporting accidents and ill health at work is
a legal requirement under The Reporting of Injuries,
Diseases and Dangerous Occurrences Regulations 2013
(RIDDOR).
 RIDDOR places a legal duty on:
 Employers
 Self-employed people
 People in control of premises.

8. Why record and report?
These 'responsible persons' must record and report certain
incidents, injuries, diseases and dangerous occurrences
involving employees, self-employed workers and members of
the public.
The information provided through recording and reporting
enables the enforcing authorities (either Health and Safety
Executive (HSE) or local authority Environmental Health), to
identify where and how risks arise, and to investigate serious
accidents.

9. What do responsible persons have to do?
Details of all reportable incidents, injuries, diseases and
dangerous occurrences must be recorded, including:
 The date when the report is made
 The method of reporting
 The date, time and place of the event
 Personal details of those involved
 A brief description of the nature of the event or disease.
Records can be kept in any form but must conform to data
protection requirements.