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Clinical Risk

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Clin Risk 2009;15:183-187
doi:10.1258/cr.2009.090018
© 2009 Royal Society of Medicine Press

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Risk Management

Reducing risk and improving quality of patient care in hospital: the contribution of standardized medical records

Mala Bridgelal Ram, Iain Carpenter and John Williams

Email: mala.bridgelalram{at}rcplondon.ac.uk

This paper addresses a range of factors in relation to the medical record and reports on a project led by the Health Informatics Unit of the Royal College of Physicians of London. It includes discussion on the need to improve the quality of the information documented, the benefits of standardizing the medical record and describes a recently completed project developing national standards for structure and content of hospital admission records, and handover and discharge documentation. It does not address the implementation of these standards in an electronic environment.


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