Full Headings Template
Publet Introduction:
The full set of record headings identifying where they are used in admission, handover, discharge, outpatient, referral records and communications and in the priority core headings
| Information | |
| Guideline Objectives | Provides the full set of record headings covering use in admission, handover, discharge, outpatient, referral records and communications and in the priority core headings. Not all headings will need to be used in all care settings or circumstances, and the order in which they appear in EHR applications, communications and letters can be agreed by system providers and end users. |
| Target Setting | Primary and hospital care |
| Target Users |
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| Overview | |
| Provenance | 7.No provenance has been assigned (default value) |
| Management | Provides the full set of record headings covering use in admission, handover, discharge, outpatient, referral records and communications and in the priority core headings. Not all headings will need to be used in all care settings or circumstances, and the order in which they appear in EHR applications, communications and letters can be agreed by system providers and end users. |
| Safety Case | These standards were developed in extensive consultation with representatives from the medical profession and specialist societies; healthcare professionals from multidisciplinary backgrounds; patients; carers and health information technology professionals. Consultations were carried out via online surveys and multi-stakeholder project workshops (www.rcplondon.ac.uk/projects/healthcare-record-standards). The development programme, the Clinical Documentation and Generic Record Standards (CDGRS) programme, was commissioned by the Health and Social Care Information Centre (originally NHS Connecting for Health) in England. It was led by the Health Informatics Unit (HIU) of the Royal College of Physicians, with the aim of producing evidence- and consensus-based national standards for the structure and content of clinical records. The standards have been endorsed as fit for purpose by 50 organisations that give professional leadership to the medical, nursing and clinical professions. They were signed off as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges in April 2013. |
| Sources | Standards for the clinical structure and content of patient records, published by the UK Health and Social Care Information Centre and Academy of Royal Colleges of Medicine |
| References |