The Academy of Medical Royal Colleges in the UK have produced a Good Practice Guide to inform hospital doctors about current developments in medical record keeping standards for the Electronic Patient Record (EPR). It describes why standards are needed for the structure and content of medical records and how their introduction will affect our work.
The document is structures as follows
– A guide for clinicians
– Why have standards for the structure and content of medical records?
– What are standards for the structure and content of medical records?
– The Electronic Patient Record
– Where are we now?
– What does it mean for me?
– What is happening next?
– Where can I get more information?
– References
The document can be accessed here - https://www.rcoa.ac.uk/sites/default/files/FPM-clinicians-guide1.pdf