Healthcare record standards

Standards for admission, handover, discharge, outpatient referral and ambulance patient records and communications are available for free and ready to use now to develop and implement in electronic health and social care records. 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) and have been adopted by the Professional Record Standards Body for Health and Social Care (PRSB).

Who's involved


  • Academy of Medical Royal Colleges

What we have produced

The standards for the clinical structure and content of patient records were published in July 2013. They were developed through extensive consultation to ensure that they address the requirements of clinicians, patients, carers and health information technology professionals.

Example templates for admission, referral, handover and discharge records have been developed to capture the information defined in the record standards.

This document defines editorial principles to govern the development of standards for the structure and content of health records.

Tools to audit patient records against the record standards have been developed to support patient safety and quality of care, professional best practice and assist compliance with Information Governance.

This report summarises the deliberations and recommendations of a Joint Working Group established in September 2010 by the Department of Health Informatics Directorate in England.

This document sets the standards for general medical record keeping by physicians in hospital practice.

The standards for patient records developed have undergone a formal risk assessment process to ensure clinical safety. At each step of the consultations to develop standards – be they workshops, meetings, national surveys – hazards were identified, reviewed and mitigations/actions considered.