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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 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.
Standards for the clinical structure and content of patient 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:
Technical, medication and medical devices annexes
We have also developed the following annexes, covering specific areas in more detail:
- Detailed report - medications and medical devices
- Technical annex - standards for admission, handover, discharge, outpatient and referral
Example templates for admission, referral, handover and discharge records have been developed to capture the information defined in the record standards.
Record keeping audit tools
Tools to audit patient records against the standards have also been developed. Please note that these tools are based on a previous version of the record standards but may still be useful for auditing records as they cover the core areas of record keeping.
- Hospital Discharge Audit Tool
- Hospital Admission Audit Tool
- Generic Multidisciplinary Clinical Record Keeping Standards Audit Tool
Editorial principles for the development of record standards
Editorial principles have been developed by the HIU to govern the development of standards for the structure and content of health records.
Professional guidance on the structure and content of ambulance records
National professional guidance for the structure and content of the clinical records of ambulance patients have also been developed by the HIU.
Developing standards for health and social care record
Joint Working Group report about the development of Electronic Health Records (EHRs) and recommendations about how professional requirements and leadership could best support the development of EHRs in line with national policy.
Generic medical record keeping standards
These 12 standards developed in 2007 set the standards for general medical record keeping by physicians in hospital practice and are applicable to any patient’s medical record.
Outline of clinical record standards development process
The process the HIU uses for developing clinical record standards is illustrated below.
Last updated on: 17 December 2014