The clinical structure and content of patient records includes standards for 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 (now called NHS Digital). 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.