Healthcare record standards

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

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.