Standards for clinical headings (AMRC 2014)

The rising demands on healthcare systems and associated costs around the world require a much more efficient and transparent means of recording, transmitting and accessing reliable clinical information in order to manage and deliver high quality care to patients, and populations.

The UK Francis Report has emphasised the need for better information and highlighted the risks that increasing service pressures bring to patients, particularly if there is more attention paid to meeting service targets than ensuring that quality of individual patient care is maintained. The challenges can only be met by the development and use of electronic health records (EHRs) in which data are recorded consistently across all contexts.

In 2014 the Royal College of Physicians of London completed an extensive project to establish standards for the high level structure of patient records ("clinical headings"), covering hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters. They were developed using published evidence and consultation with doctors, patients, nurses and allied healthcare professionals. The standards were signed off as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges and published in April 2013.

The implementation of national standards for the clinical structure and content will facilitate shared care, enable interoperability between locations and contexts, and yield comparable data to support the management and monitoring of services realising benefits for patients, clinicians and healthcare providers.

Core Headings Template

Core headings described in the RCP document

Handover Headings Template

Headings for use during Handover

Referral Headings Template

Headings for use during Referral

Discharge Headings Template

Headings for use when documenting discharge of a patient from an NHS Hospital

Admission Headings Template

Headings for use when patients are admitted to hospital in the NHS

Outpatient Headings Template

Headings for use in an Outpatient setting

Full Headings Template

All headings described in the RCP document

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