Developing Professional Record Keeping Standards & Clinicians Guides, 2008
Developing professional record keeping standards, April 2008
With funding from NHS Connecting for Health, a project was co-ordinated 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
Clinicians guides to medical record standards, October 2008
A guide has been published for clinicians on the standards for the structure and content of medical records.
- Clinicians guide part 1 - Why standardise the structure and content of medical records? Provides the background and context of the development of the standards.
- Clinicians guide part 2 - Standards for the structure and content of medical records on patient admission. Provides the standard headings and definitions of the hospital admission records, and handover and discharge communications.
Both parts are available for dowload below. Free copies can also be ordered from the Health Informatics Unit.
