PT  - JOURNAL ARTICLE
AU  - Iain Carpenter
AU  - Mala Bridgelal Ram
AU  - Giles P Croft
AU  - John G Williams
TI  - Medical records and record-keeping standards
AID  - 10.7861/clinmedicine.7-4-328
DP  - 2007 Aug 01
TA  - Clinical Medicine
PG  - 328--331
VI  - 7
IP  - 4
4099  - http://www.rcpjournals.org/content/7/4/328.short
4100  - http://www.rcpjournals.org/content/7/4/328.full
SO  - Clin Med2007 Aug 01; 7
AB  - 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.