Section 4 of the ‘Standards for the Clinical Structure and Content of Patient Records’ focuses on discharge record headings. These headers include (but are not limited to) demographic information, details of the admission and discharge, medication information, capacity related information and details of the information given to the patient.
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.
https://digital.nhs.uk/article/249/Our-Strategy, accessed 20.4.17
Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link.
TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link.
Responses: If you have any comments, you can leave them below or alternatively e-mail email@example.com.
Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.
Conflicts of Interest: *For potential conflicts of interest please see the About section