Referral Headings Template

This publet is a template for the structure and content of patient information that is to be recorded when patients are referred for care between professionals and services. The referral headings are primarily intended for recording the clinical information in communications between GPs and hospital doctors, and copied to the patient. However, they may be used for other types of referral.

It has been enhanced for OpenClinical.net in order to promote use of a common framework for documenting patient admissions 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 a patient may require admission into a hospital. 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 one section of the RCP standard, referral, but templates for the full standard, covering hospital admission, inpatient clerking, handover communications, discharge summaries and outpatient letters, are also available on OpenClinical.net.