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Clinical Documentation & Generic Record Standards

The standards for the clinical structure and content of patient records (CDGRS) Project commissioned by the Health and Social Care Information Centre (HSCIC) has now produced a report via the Academy of Medical Royal Colleges (AoMRC) on the standards for the clinical structure and content of patient records.

The standards are based on evidence and consensus of the clinical professions and provide the only viable approach to implementing integrated digital care records in the NHS.  They will improve the quality and safety of individual patient care, and the validity of data extracted from patient records for service and performance management, commissioning, audit and research.  Specifically, they will support the digitisation of several clinical processes, including e-referrals, discharge summaries, outpatient letters, e-prescribing and medications management,  admission and handover.

High quality digital care records would enable earlier identification of developing problems with care standards.  They will also provide a much richer source of information than the highly publicised Standardised Mortality Ratios.

The Health Informatics Unit (HIU) at the Royal College of Physicians (RCP) is keen to work with NHS Trusts to support the implementation of the standards in integrated digital care records, to meet the Secretary of State for health’s challenge to the NHS to ‘go paperless’ by 2018.

You can contact the Associate Director of the HIU Professor Iain Carpenter by email: Iain.carpenter@rcplondon.ac.uk
or see more details on the website

Download standards for the clinical structure and content of patient records(5Mb)

Standards for the clinical structure and content of patient records

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