Standards for the Clinical Structure and Content of Patient Records: All Record Headings

Section of the Standards for the Clinical Structure and Content of Patient Records is titled ‘All Headings’. This references all headings in the document against 6 heading domains – core headings, admission, handover, discharge, outpatient and referral. These core headings form the subsequent six sections of the document.

What are the Standards for the Clinical Structure and Content of Patient Records?

The standards are a publication of the Health and Social Care Information Centre (now NHS Digital) and the Academy of Medical Royal Colleges and were published in July 2013 (HSCIC, 2017). The standards were prepared by the Royal College of Physicians on behalf of the Health and Social Care Information Centre.  The standards were developed for the recording and integration of information in electronic patient records and to facilitate the use of this information for a range of functions including but not limited to commissioning, performance management and research. These standards were referenced in the HSCIC 5-year strategy.

What is the ‘Information and Technology for Better Care’ Paper?

NHS Digital (formerly known as The Health and Social Care Information Centre) published a 5 year strategy in 2015 titled ‘Information and Technology for Better Care’. This document covers a number of areas.

References

https://digital.nhs.uk/article/249/Our-Strategy, accessed 20.4.17

https://www.rcplondon.ac.uk/projects/outputs/standards-clinical-structure-and-content-patient-records, accessed 1.5.2017

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