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Lack of national software for care records makes implementing national record standards even more important says RCP

Responding to the recent National Audit Office report on the delivery of detailed care records, the directors of the Royal College of Physicians’ (RCP) Health Informatics Unit (HIU) agree that the delivery of a central system for care records is not achievable. Instead, Professors John Williams and Iain Carpenter say that the way forward is to implement national standards for the structure and content of care records from a clinical perspective.

The RCP’s HIU led the development of the standards , which were endorsed by the Academy of Medical Royal Colleges in a project funded by NHS Connecting for Health, and can be used anywhere in the NHS with different software systems.

In this way, a patient focussed record can be developed. In a single health economy this might use a single technical solution, but the implementation of such standards would not make this imperative, and would support the consistent and safe recording of patient data, and transfer of clinical information at the interface between different contexts of care.

This approach ensures that the quality of the information is high because it is used in everyday patient care. In addition, the standards for the structure and content of medical records ensure that relevant clinical information can be extracted and aggregated to support policy, management, audit and research.