New national standards on medical records

15 January 2010

A NEW set of national standards on what medical records should contain has been published.

The Royal College of Physicians (RCP) has been working with other medical royal colleges to develop a system detailing the standard content and structure of records in the UK. These standards have been approved by the Academy of Medical Royal Colleges (AoMRC) and are now national standards for the medical profession.

They are evidence-based consensus standards and include elements such as generic medical record keeping standards that would apply to all medical notes. There are also standards for:

• The admission clerking record
• The inpatient handover record (shift handover including hospital at night and handovers between consultant teams)
• Discharge from hospital.

These are published in two Guides for Clinicians

See example templates for admission, handover and discharge here

Tools for auditing notes and e-learning tools are also available on the RCP website.