Based on the work of the Health Informatics Unit, a guide has been published for clinicians on the standards for the structure and content of medical records.
Part one provides the background and context of the development of the standards.
A Clinicians Guide to Record Standards - Part 1: Why standardise the structure and content of medical records? (PDF 604KB 
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Part two provides the standard headings and definitions of the hospital Admission Records, and Handover and Discharge Communications.
A Clinicians Guide to Record Standards - Part 2 : Standards for the structure and content of medical records and communications when patients are admitted to hospital. (PDF 379KB )
Free copies can also be ordered online using the link below, delivery is usually within 2 working days.