Healthcare record standards

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:

• Standards for the clinical structure and content of patient records

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

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.