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The latest version of the healthcare record standards have been endorsed as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges (AoMRC). Standards for admission, handover, discharge, outpatient and referral records and communications are available for free and ready to use now to develop and implement electronic health and social care records.
These standards were produced in the Clinical Documentation and Generic Record Standard (CDGRS) programme, commissioned by the Health and Social Care Information Centre (HSCIC), and can be found in the following report:
Other reports, covering specific areas in more detail are also available as follows:
- Project report - standards for admission, handover, discharge, outpatient and referral records
- Project report - referral letter standards
- Project report - outpatient record and communications standards
- Detailed report - medications and medical devices
- Technical annex - standards for admission, handover, discharge, outpatient and referral
The Health Informatics Unit (HIU) contributes to improving the quality of patient care through developing standards for the structure and content of healthcare records. The development of these standards include extensive consultation with stakeholders include healthcare professionals from multi-disciplinary backgrounds, patients, carers and health information technology professionals.
The process used for developing clinical record standards is illustrated below.
Outline of clinical record standards development process
Further information on previous phases of the CDGRS programme can be found below:
- generic health record keeping standards
- admission record standards
- handover record standards
- referral record standards
- hospital discharge record standards
- outpatient record standards
- core headings.
For further information please contact us at firstname.lastname@example.org.
Last updated on: 22 August 2013