Medical records and record-keeping standards.
The structure of medical records becomes ever more critical with the advent of electronic records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Records 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. Generic medical record-keeping standards are now available.
Carpenter
Iain
I
Health Informatics Unit, Royal College of Physicians. Regent's Park, London. iain.carpenter@rcplondon.ac.uk
Ram
Mala Bridgelal
MB
Croft
Giles P
GP
Williams
John G
JG
D017050:Episode of Care; D006779:Hospitals, Public; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration / Q000592:standards*; D011785:Quality Assurance, Health Care; D012308:Risk Management; D013222:State Medicine; D006113:United Kingdom