Structure and content of health and care records

Which standards have changed?

The following PRSB standards have been updated in this release. Detailed release notes are available for each standard outlining the changes made. Please use the links below.


The PRSB structure and content of health and care records is the essential resource that describes the standardised information that should be gathered and shared in care records so that they can be exchanged digitally across the NHS and social care, whenever and wherever it is needed.

Revised standards

PRSB has revised and aligned its standards to support the digital exchange of health and care records and communications using technology called Fast Healthcare Interoperability Resources (FHIR). When combined, standardised care records and FHIR technology will allow information to flow directly from one IT system to another helping people to access safe, high quality, timely and efficient care. INTEROPen has published the first FHIR profiles, which will support the transfer of information between different systems.

The new 2018 PRSB Standards for the Structure and Content of Health and Care Records replaces the 2013 Standards for the Clinical Structure and Content of Patient Records. This publication has been updated to reflect current professional practice and incorporates new or changed record structures and content resulting from the development of detailed transfer of care standards and integrated care standards.  The changes can be viewed in detail here.

How has PRSB completed this work?

The standards have been developed with input from thousands of professionals from all health and social care specialties, carers and people who access services. They agreed what information is essential to share in order to provide timely, high quality care efficiently that is well-coordinated and meets an individual’s needs.

This is the first major release since 2013 and PRSB has produced guidance and FAQs to help organisations and system suppliers replace previous versions of the standards in their information systems.

For more information or help with queries contact the PRSB at or phone 020 7922 7976.