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Standards for admission, handover, discharge, outpatient and referral – technical annex

The document is not intended to provide a technical specification to be used in implementing the headings on electronic health record (EHR) systems.

Although this report includes headings for medicines and medical devices, a seperate technical annex has also been produced specifically for medicines and medical devices, which discusses technical issues regarding the implementation of standards in this area.

The intended audience for this report is primarily informaticians, both at a local and national level, and healthcare IT system vendors.

These standards were developed through the Clinical Documentation & Generic Record Standards (CDGRS) project commissioned by the Health and Social Care Information Centre (HSCIC).

They were signed off as fit for purpose for the clinical professions by the Academy of Medical Royal Colleges (AoMRC) in April 2013.

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