Background
Medical records are an integral part of effective patient care. They are used not only for primary clinical purposes but also for secondary purposes including reporting the activity of hospital services, monitoring performance of hospitals and for research. They remain the most important focus of any patient complaint or litigation.
Problems with the structure and content of medical records and record-keeping were reported by the Audit Commission (1995 and 1999), highlighting the need for improved practices and standards.
The Royal College of Physicians (RCP) HIU audited 149 case notes in five hospitals in England and Wales in 2002 and examined the completeness, specific features of individual entries and also the quality of printed discharge summaries. There was widespread inconsistency of content and structure of records, compounded by different hospital practices that made comparisons difficult.
Developing Professional Record Keeping Standards
With funding from Connecting for Health, the HIU has been co-ordinating a project to develop medical profession-wide standards for the content structure of hospital admission records, handover and discharge communications.
The process of literature review, drafting, extensive consultation and redrafting has ensured that there has been large scale clinical engagement and specialist contribution to the development of the standards. The standards were approved as fit for purpose by the Academy of Medical Royal Colleges on 17 April 2008.
Summary for the Academy of Medical Royal Colleges (PDF 81KB 
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The Standards for the Hospital Admission, Handover and Discharge Records are contained in the Clinician's Guides:
Further information