Medical records and record-keeping standards

Abstract

The structure of medical records becomes ever more critical with the advent of electronic medical records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Record Standards Programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Laboratory (iLab) focuses on Hospital Episode Statistics and their use for monitoring clinician performance. Clinician endorsement of the work is achieved through extensive consultations. The Generic Medical Record Keeping Standards are published in this issue of Clinical Medicine