摘要：Medical data recording is one of the basic clinical tools. Electronic Health Record (EHR) is important for data processing, communication, efficiency and effectiveness of patients’ information access, confidentiality, ethical and/or legal issues. Clinical record promote and support communication among service providers and hence upscale quality of healthcare. Qualities of records are reflections of the quality of care patients offered. Qualitative analysis was undertaken for this systematic review. We reviewed 40 materials Published from 1999 to 2013. We searched these materials from databases including ovidMEDLINE and ovidEMBASE. Two reviewers independently screened materials on medical data recording, documentation and information processing and communication. Finally, all selected references were summarized, reconciled and compiled as one compatible document. Patients were dying and/or getting much suffering as the result of poor quality medical records. Electronic health record minimizes errors, saves unnecessary time, and money wasted on processing medical data. Many countries have been complaining for incompleteness, inappropriateness and illegibility of records. Therefore creating awareness on the magnitude of the problem has paramount importance. Hence available correct patient information has lots of potential in reducing errors and support roles.
关键词：Medical data ; Documentation ; Decision making ; Electronic health record ; Health service quality
