Structure and content of medical notes

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 audited case notes from England and Wales in 2002 and found widespread inconsistency in the content and structure of records, compounded by different hospital practices.  This made it almost impossible to compare the quality of information written in medical notes.  In order to address these problems the 12 Generic Medical Record Keeping Standards were developed and launched in 2007 and 2008.

• Improving clinical records, project with audit commission (August 2009)
• Developing professional record keeping standards & clinicians guides (2008)
• Hospital admission, handover and discharge standard development (2007-8)
• Generic record keeping standards (2007)

Generic record keeping standards, 2007-8

Generic Medical Record Keeping Standards for physicians that are applicable to any patient’s medical record were developed. Twelve standards received formal RCP approval from the Royal College of Physicians Clinical Standards Board meeting in March 2007.  First published in the Royal College of Physicians journal ‘Clinical Medicine’ in August 2007 and republished with the Academy of Medical Royal Colleges in 2008 in A Clinicians Guide to Record Standards.

The standards in summary:

• contribute to maximising patient safety and quality of care (through improved completeness of documentation by clinicians and improved clinical performance)
• support professional best practice
• assist compliance with Information Governance and NHS Litigation Authority Clinical Negligence Scheme for Trusts)  standards.

Audit tool for the generic standards, May 2009

We developed an audit tool to support the implementation of the generic medical record-keeping standards. This tool was piloted in a number of hospital settings and was made available online May 2009.