Medical records and record-keeping standards

Carpenter, I. and Bridgelal Ram, Mala and Croft, Giles and Williams, John (2007) Medical records and record-keeping standards. Clinical Medicine, 7 (4). pp. 328-331. ISSN 1470-2118. (Full text available)

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Abstract

The structure of medical records becomes ever more critical with the advent of electronic medical records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Record Standards Programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Laboratory (iLab) focuses on Hospital Episode Statistics and their use for monitoring clinician performance. Clinician endorsement of the work is achieved through extensive consultations. The Generic Medical Record Keeping Standards are published in this issue of Clinical Medicine.

Item Type: Article
Uncontrolled keywords: medical records, performance monitoring, risk management standards, structured documentation
Subjects: R Medicine
Divisions: Faculties > Social Sciences > School of Social Policy Sociology and Social Research
Depositing User: Iain Carpenter
Date Deposited: 29 Jun 2011 19:24
Last Modified: 20 Jan 2012 11:28
Resource URI: http://kar.kent.ac.uk/id/eprint/15480 (The current URI for this page, for reference purposes)
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