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Standards for the clinical structure and content of patient records

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.

They are needed to:

  • ensure that information can be recorded and integrated in electronic patient care records across professions, disciplines and specialities, while properly reflecting best practice
  • generate data that can be used for service delivery and performance management, commissioning, audit and research from data recorded for patient care at the point of care.

These standards were developed for use by:

  • clinicians and healthcare professionals from across all clinical disciplines
  • those who develop and implement electronic or paper care records.

Who's involved


  • Academy of Medical Royal Colleges
  • Association for Clinical Biochemistry
  • Association for Palliative Medicine of Great Britain & Ireland
  • Association of British Clinical Diabetologists
  • Association of Cancer Physicians
  • Association of Surgeons of Great Britain and Ireland
  • British Association for Parenteral & Enteral Nutrition
  • British Association of Audiovestibular Physicians
  • British Association of Dermatologists
  • British Association of Otorhinolaryngology (Ears, Nose and Throat) (ENT – UK)
  • British Association of Plastic, Reconstructive and Aesthetic Surgeons
  • British Association of Stroke Physicians
  • British Association of Urological Surgeons
  • British Cardiovascular Society
  • British Dietetic Association
  • British Geriatrics Society
  • British Infection Association
  • British Orthodontic Society
  • British Orthopaedic Association
  • British Pain Society
  • British Psychological Society
  • British Society for Gastroenterology
  • British Society for Haematology
  • British Society for Genetic Medicine
  • British Society for Immunology
  • British Thoracic Society
  • Chartered Society of Physiotherapy
  • Chronic Pain Policy Coalition (CPPC)
  • Clinical Genetics Society
  • College of Emergency Medicine
  • College of Occupational Therapists
  • Faculty of Occupational Medicine
  • Faculty of Sport and Exercise Medicine
  • Health and Social Care Information Centre
  • Intensive Care Society
  • Renal Association
  • Royal College of Anaesthetists
  • Royal College of General Practitioners
  • Royal College of Midwives
  • Royal College of Nursing
  • Royal College of Obstetricians and Gynaecologists (RCOG)
  • Royal College of Ophthalmologists
  • Royal College of Paediatrics and Child Health
  • Royal College of Pathologists
  • Royal College of Physicians and Surgeons Glasgow
  • Royal College of Physicians of Edinburgh
  • Royal College of Psychiatrists
  • Royal College of Radiologists
  • Royal College of Surgeons of Edinburgh
  • The Royal College of Surgeons of England
  • Royal Pharmaceutical Society (RPS)
  • Society of British Neurological Surgeons