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.

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
  • to 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.