Update September 2013: This year the 2008 standards for admission, handover and discharge (on which the below audit tools are based) have been reviewed and updated and new standards have been released for outpatient and referral records.
Background: Clinical records are fundamental to the quality and safety of patient care. There is abundant reported evidence of poor clinical records and they are a frequent factor in clinical incidents. Part of the problem has been that clinicians learn to write clinical notes more by apprenticeship than by the application of established standards. In 2008 the Health Informatics Unit at the Royal College of Physicians (RCP) published standards for the structure and content of admission, handover and discharge records in a two-part guide.
The Project: Implementation of the standards, and monitoring performance against the standards, should help to improve patient safety and quality of care. In a project funded by the HQIP, the Health Informatics Unit have developed tools for auditing patient records against generic record-keeping standards, standards for admission clerking and discharge summaries. The audit tools were tested in hospital pilots and structured into the current software. The nursing, midwifery and allied health professionals' organisations and the NHS Litigation Authority contributed to the development and evaluation of the generic standards and the audit tool to ensure that they are fit for purpose for these professions. Evidence from the audit tool can be used by NHS providers in NHSLA assessments, although it should be noted that evidence is required on records from all professions.
Three audit tools are available for download and for auditing against the standards:
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