Standards for the Structure and Content of Patient Records (RCP)

Summary

The Royal College of Physicians (RCP)’s healthcare record standards covers the recommended clinical structure and content of electronic health records. Section headings in this report comprise:

  • Introduction.
  • Standardised electronic health records.
  • Developing the standards.
  • Using the standards.
    • Section 1: All record headings.
    • Section 2: Admission record headings.
    • Section 3: Handover record headings.
    • Section 4: Discharge record headings.
    • Section 5: Outpatient record headings.
    • Section 6: Referral record headings.
    • Section 7: Core clinical headings.
  • Organisations contributing to the review of all record standards headings.
  • Organisations which signed off the record standards headings.

“Implementation of these record standards will help to bring about a system where a patient’s record can follow them as they move between care settings, whether across primary, secondary, or mental health and community care. Different headings apply in different settings; clinicians don’t need to use all the headings every time. These standards have been developed to reflect the way patients and clinicians work together”.

Read more: Stop reinventing the wheel! Standards for the clinical structure and content of patient records formally launched. Royal College of Physicians.

Full Text Link

Reference

Standards for the clinical structure and content of patient records. London: Royal College of Physicians (RCP), July 11th 2013.

Alternative (Official) Reference

Health and Social Care Information Centre, Academy of Medical Royal Colleges (2013). Standards for the clinical structure and content of patient records. London: HSCIC, 2013.

[A brief reference to this item features in Dementia and Elderly Care: the Latest Evidence Newsletter (RWNHST), Volume 3 Issue 9, August 2013].

About Dementia and Elderly Care News

Dementia and Elderly Care News. Wolverhampton Medical Institute: WMI. (jh)
This entry was posted in Acute Hospitals, Community Care, For Doctors (mostly), For Nurses and Therapists (mostly), For Researchers (mostly), Guidelines, Integrated Care, National, NHS, Patient Care Pathway, Person-Centred Care, Practical Advice, Quick Insights, Royal College of Physicians, Standards, UK, Universal Interest and tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink.

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