01 July 2013
Standards for the clinical structure and content of patient records
Standards for the clinical structure and content of patient records is the latest complete set of UK standards, published in 2013. It was signed off as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges (www.aomrc.org.uk).
This document describes standards for the structure and content of patient records, covering hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters. These standards were developed in extensive consultation with representatives from the medical profession and specialist societies; healthcare professionals from multidisciplinary backgrounds; patients; carers and health information technology professionals. Consultations were carried out via online surveys and multi-stakeholder project workshops.
The development programme was commissioned by the Health and Social Care Information Centre (originally NHS Connecting for Health) in England. It was led by the Health Informatics Unit (HIU) of the Royal College of Physicians, with the aim of producing evidence and consensus-based national standards for the structure and content of clinical records. The standards have been endorsed as fit for purpose by 50 organisations that give professional leadership to the medical, nursing and clinical professions.