This report, published in April 2013, sets the standards for medication and medical device records.
- This annex was produced because there are specific issues which need to be resolved in implementing a standard format for electronic medication records.
- The report is primarily intended for informaticians, at both a national and local level and for EHR and pharmacy system vendors.
The scope of the medication record headings is intended to cover both hospital and community settings, including primary care and pharmacies. It does not include patient records, ie patients recording the medications that they are taking.
These standards were developed through the Clinical Documentation & Generic Record Standards (CDGRS) project commissioned by the Health and Social Care Information Centre (HSCIC).
They were signed off as fit for purpose for the clinical professions by the Academy of Medical Royal Colleges (AoMRC) in April 2013.