A clinicians’ guide to record standards - Gateway reference number: 10508

The Royal College of Physicians (RCP) in partnership with NHS Connecting for Health has developed standards for hospital patient records, approved by the Academy of Medical Royal Colleges. The new standards will improve patient safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.

See the RCP website for further details: http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/Overview.aspx

The standards are accompanied by a two-part clinicians' guide:

• Part 1 (PDF 603Kb) - informs about current developments in medical record keeping standards for the Electronic Patient Record. It describes why standards are needed for the structure and content of medical records and how their introduction will affect the work of hospital clinicians.
• Part 2 (PDF 374Kb) - contains the new standards plus standard headings and definitions of the hospital Admission Records, and Handover and Discharge Communications.

Hard copies of both parts can be ordered via the NHS CFH Resources pages. Please visit: http://information.connectingforhealth.nhs.uk > Digital Health Information Policy > Booklet

Records Management Roadmap

The Records Management Roadmap contains a range of practical tools and guidance designed to support organisations in the implementation of an effective records management system in line with the principles contained in the Records Management: NHS Code of Practice.

The Roadmap comprises 'how to' materials in the form of templates and checklists to assist organisations in developing and implementing solid records management processes. It complements the guidance and knowledge-based materials in the Information Governance Toolkit.

The Roadmap is in electronic format only, available via this website, enabling speedy updates to be made when new material is produced. The release of the Roadmap will be phased. The current content includes guidance on:

• An Approach to Records Management Audit v1.0 (PDF, 165Kb)
• A Model Records Management Policy (Word, 103Kb)
• A Model Records Management Strategy (Word, 168Kb)
• A Records Inventory Survey Template (Word, 76Kb)
• Electronic records inventory form definitions (Word, 64Kb)
• Electronic records inventory survey form (Excel, 160Kb)
• Manual records inventory form definitions (Word, 68Kb)
• Manual records inventory survey form (Excel, 72Kb)
• Raising the profile of records management - 'Getting Started' (Word, 155Kb)
• The Roadmap Framework v1.3 (PDF, 207Kb)

Records Management: NHS Code of Practice

Visit NHS Codes of Practice and legal obligations for the 'Records Management: NHS Code of Practice'.

Training modules

To view the speaker notes for the presentations (PPT files) whilst online, open the file, right click on the first slide, then in PowerPoint 2002 select "Speaker Notes", in PowerPoint 2003 select "Edit Slides".

• Corporate Records Management: Practitioner level training presentation (PPT 365Kb)
• Health Records Management: Foundation level training presentation (PPT 141Kb)
• Health Records Management: Practitioner level training presentation (PPT 266Kb)
• Outline Records Management training modules v1.0 (PDF 13Kb)
• Records Management and the NHS Code of Practice: Foundation level training presentation (PPT 912Kb)

Other guidance material may be added later.