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Medical records and record-keeping standards

By G. Iain Carpenter, Mala Bridgelal Ram, Giles Croft and John Williams

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

Topics: R
Year: 2007
OAI identifier: oai:kar.kent.ac.uk:15480

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Citations

  1. Improving standards in clinical record-keeping. Adv psychiatric treatment 2006;12:280–6.
  2. The RCP Information Laboratory (iLab): breaking the cycle of poor data quality.

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