RCP/AoMRC's new national medical records system now available
Published: 10/12/2009 08:10:00
The Royal College of Physicians (RCP) has been working with the other medical royal colleges to develop standards for what medical records should contain and the way they should be structured for patients admitted to hospital. These were approved by the Academy of Medical Royal Colleges (AoMRC) and are now national standards for the medical profession. They are evidenced-based consensus standards and some of the products of this programme of work include:
- Generic Medical Record Keeping Standards that are applicable for any medical notes
- Standards for the
1. Admission clerking record
2. Inpatient handover record (shift handover including Hosptial at Night, and consultant team-consultant team handover)
3. Discharge from hospital
These are published in two Guides for Clinicians http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/clinicians-guides.aspx - Example templates for admission, handover and discharge http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/templates.aspx
- Audit Tool to audit notes against the Generic Medical Record Keeping Standards: http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/generic-standards.aspx
- E-Learning Tools (available late January)
1. Module 1- The importance of good clinical record keeping
2. Module 2- Standards for inpatient medical records
http://www.rcplondon.ac.uk/CLINICAL-STANDARDS/HIU/Pages/Resources.aspx
For further information please email informatics@rcplondon.ac.uk
