Core Headings Template

This publet is a machine-readable model of core clinical headings covering SNOME CT items that are priority for inclusion in electronic health records (EHRs). It has been enhanced for OpenClinical.net in order to promote use of a common framework for documenting patient care in structured, machine-readable formats for storage in electronic medical records. The headings are based on a standard developed by the Royal College of Physicians of London and published with the support of the UK Health and Social Care information Centre and Academy of Medical Royal Colleges.  

This machine-interpretable version of the standard provides the clinical record headings and a description of the information that should be recorded under each heading. OpenClinical.net members can import the template into applications where it is envisaged that use of standard clinical data would be desirable. Individual specialties and services will require headings and information in addition to, and different from, the generic data supported by the standard and the template. The additional heading standards will be developed by those specialties and should be accommodated under the generic headings.

This publet focuses on the core headings of the RCP standard but templates for the full standard, covering hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters, are also available on OpenClinical.net.