Standards for the clinical structure and content of patient records
The standards for the clinical structure and content of patient records were published in July 2013 by the Academy of Medical Royal Colleges. They were developed through extensive consultation to ensure that they address the requirements of clinicians, patients, carers and health information technology professionals.
They are needed:
- to ensure that information can be recorded and integrated in electronic patient care records across professions, disciplines and specialities, while properly reflecting best practice
- to generate data that can be used for service delivery and performance management, commissioning, audit and research from data recorded for patient care at the point of care.
These standards were developed for use by:
- clinicians and healthcare professionals from across all clinical disciplines
- those who develop and implement electronic or paper care records.
Download the standards for the clinical structure and content of patient records here.
Helping to reduce prescribing errors by developing standards for the design of hospital in-patient prescription charts
The Academy of Medical Royal Colleges together with the Royal Pharmaceutical Society (RPS) and Royal College of Nursing (RCN) has produced a report on standards for the design of hospital in-patient prescription charts. The Academy wishes to promote these standards throughout the NHS. The standards were developed by an inter-professional group of doctors, pharmacists and nurses drawn from the medical Royal Colleges, the RPS and the RCN, who reviewed hospital prescription charts from a variety of sources, examined the scientific publications in the area and consulted widely with colleagues in their own organisations and in the NHS using an extensive iterative approach before finalising the recommendations outlined in the report.
For full report and appendices please click here