The fifth section of the ‘Standards for the Clinical Structure and Content of Patient Records’ relates to Outpatient Headings. Many of the sections are similar to the Inpatient Headings which follows from the shared assessment and management functions. There are demographic sections, referrer details, history, examination, investigations and even a distribution list. There is also a heading for the details of the person completing the records.
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
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