The Standards for the Clinical Structure and Content of Patient Records: Core Clinical Headings

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The seventh section of the ‘Standards for the Clinical Structure and Content of Patient Records’ relates to Core Clinical Headings. Many of the headings here overlap with those in previous sections. As with the previous section headings include demographic data,    assessment scales, investigations and medication. In the documentation it is noted that these core headings are a priority for SNOMED CT coding.

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.

What is SNOMED CT®?

SNOMED CT® is a systematised health terminology used internationally maintained by the International Health Terminology Standards Development Organisation (IHTSDO).

SNOMED CT® Posts

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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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

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