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Medical records and record-keeping standards

Iain Carpenter, Mala Bridgelal Ram, Giles P Croft and John G Williams
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DOI: https://doi.org/10.7861/clinmedicine.7-4-328
Clin Med August 2007
Iain Carpenter
Health Informatics Unit, Royal College of Physicians
Roles: Professor, Human Ageing, Clinical Lead, Records Standards
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Mala Bridgelal Ram
Health Informatics Unit, Royal College of Physicians
Roles: Project Manager, Records Standards
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Giles P Croft
Health Informatics Unit, Royal College of Physicians
Roles: Project Manager, iLab
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John G Williams
Health Informatics Unit, Royal College of Physicians
Roles: Professor, Health Services Research Director
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Abstract

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.

KEY WORDS
  • medical records
  • performance monitoring
  • risk management standards
  • structured documentation
  • © 2007 Royal College of Physicians
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Medical records and record-keeping standards
Iain Carpenter, Mala Bridgelal Ram, Giles P Croft, John G Williams
Clinical Medicine Aug 2007, 7 (4) 328-331; DOI: 10.7861/clinmedicine.7-4-328

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Medical records and record-keeping standards
Iain Carpenter, Mala Bridgelal Ram, Giles P Croft, John G Williams
Clinical Medicine Aug 2007, 7 (4) 328-331; DOI: 10.7861/clinmedicine.7-4-328
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