Medical Record Keeping

Example templates: hospital admission, handover and discharge  

To test the usability of the headings they were piloted in paper format in a number of hospital sites. From the feedback received and a further workshop with clinicians, the HIU is developing example templates. The current draft templates can be downloaded and tailored to the specific requirements of individual hospitals and Trusts to create paper proformas.

 

 

The publication 'Clinicians Guide to Record Standards- Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital' contains the standard headings and definitions and a guide to those headings which should be used in paper format.