Outptient Headings Template

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Description: Headings for use in an Outpatient setting

Publet Introduction:

The clinical information recorded in an outpatient setting, including the initial and follow-up outpatient visits, and the information included in the outpatient letter to the GP and patient. The outpatient standards also include the administrative information that precisely defines the attributes of outpatient and ambulatory care sessions.

This publet is a template for the structure and content of patient information that is to be recorded when a patient is an outpatient in a hospital in the UK National Health Service. It has been enhanced for OpenClinical.net in order to promote use of a common framework for documenting patient admissions in structured, machine-readable formats for storage in electronic medical records. The headings are based on a standard developed by the Royal College of Physicians of London and published with the support of the UK Health and Social Care information Centre and Academy of Medical Royal Colleges.  

This machine-interpretable version of the standard provides the clinical record headings and a description of the information that should be recorded under each heading. OpenClinical.net members can import the template into applications where it is envisaged that a patient may require admission into a hospital. Individual specialties and services will require headings and information in addition to, and different from, the generic data supported by the standard and the template. The additional heading standards will be developed by those specialties and should be accommodated under the generic headings.

This publet focuses on outpatient care, but templates for the full standard, covering hospital referral letters, hospital admission, inpatient clerking, handover communications, discharge summaries and outpatient letters, are also available on OpenClinical.net. 

Guideline objectives

Outpatient record standards: standard headings for the clinical information to be recorded when a patient is being seen as an outpatient in an NHS hospital.

Not all headings will need to be used in all care settings or circumstances, and the order in which they appear inEHR applications, communications and letters can be agreed by system providers and end users.

Target setting Hospital departments and clinics
Target users Clinical and administrative staff
Provenance 3. Represents the current consensus about best practice in its focal area
  • Author: Omar Khan
  • Release date: 2013-07-01
  • Status: Draft - Under Review
  • History: Edited on 14/1/2014
Safety case These standards were developed in extensive consultation with representatives from the medical profession and specialist societies; healthcare professionals from multidisciplinary backgrounds; patients; carers and health information technology professionals. Consultations were carried out via online surveys and multi-stakeholder project workshops (www.rcplondon.ac.uk/projects/healthcare-record-standards). The development programme, the Clinical Documentation and Generic Record Standards (CDGRS) programme, was commissioned by the Health and Social Care Information Centre (originally NHS Connecting for Health) in England. It was led by the Health Informatics Unit (HIU) of the Royal College of Physicians, with the aim of producing evidence- and consensus-based national standards for the structure and content of clinical records. The standards have been endorsed as fit for purpose by 50 organisations that give professional leadership to the medical, nursing and clinical professions. They were signed off as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges in April 2013.

Standards for the clinical structure and content of patient records, published by the UK Health and Social Care Information Centre and Academy of Royal Colleges of Medicine