Directory of European Resources > Eurocleft Clinical Network > Consensus Recommendations > General Principles Governing Record Taking

• clinical records should be taken for individual patients to allow treatment planning, monitoring treatment progress and treatment evaluation.
• the timing and nature of these records will depend on the clinical protocols followed by individual teams.
• treatment and associated record taking protocols should be agreed and clearly set out by the cleft team.

2. Records for Quality Improvement/Research

Additional records may be taken for a number of other reasons:

• follow up of a series of patients to provide an overview of the outcome of care.
• to allow retrospective comparisons of different protocols.
• as part of a prospective clinical trial with ethical approval.
• as part of an agreed protocol for intercentre quality improvement comparisons or comparison against known standards.
• as part of an agreed research protocol.
• other reasons such as medico-legal, second opinion.

3. Safeguards

• exposure of patients to unnecessary radiation should be avoided.
• research and quality improvement records should only be taken when there is an established
• written protocol on how they will be put to use.
• research and quality improvement records should not be taken without the consent of the patient/parent/guardian.
• research and quality improvement records should coincide as far as possible with the records for treatment planning/monitoring (statement 1).