The latest record standards have been approved by the Academy of Medical Royal Colleges (AoMRC). Standards for admission, handover, discharge, outpatient and referral records and communications have been revised and updated as part of phases 2 and 3 of the Clinical Documentation and Generic Record Standards (CDGRS) project.
Commenting on the updated standards, Prof Iain Carpenter Associate Director of the RCP Health Informatics Unit (HIU) said,
These national standard headings will provide a major contribution to whatever actions are taken by the Department of Health (DH) and NHS England to meet the challenge of a ‘paperless’ NHS by 2018. If there is any chance of achieving this ambitious goal, it will have to be based on electronic patient records (EPRs) in every Trust by 2018. EPRs have to reflect the way we work – standards set by the professions are our best chance to achieve this.
The RCP’s HIU won the contract for this work in 2010 and has been working with nominees from all clinical professional bodies and associations and the Health and Social Care Information Centre (HSCIC) to revise the standards. The updated versions of healthcare record standards are all designed to be suitable to use in electronic health records (EHR) and electronic communications.
The standards are now available online and will be formally launched in July 2013.