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:
- 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”.
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].