Clinical

RCP Tools for Auditing Patient Records

11 April 2012

The RCP's Health Informatics Unit (HIU) has developed three tools for auditing patient records against the HIU standards covering generic record-keeping standards, standards for admission clerking and discharge summaries. More information about the 3 tools can be found at HIU Tools for Record Keeping. 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; improvements in written clinical notes through application of agreed standards should help to improve patient safety and quality of care.