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The structure of medical records becomes ever more critical with the advent of electronic records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Records Standards programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and(More)
BACKGROUND Assessment was identified as one of the 'cornerstones' of community care. This study presents findings from the first nationally representative analysis of assessment documents used by social services agencies in the UK. METHOD In this paper analysis is made of 50 assessment documents used for the 'comprehensive' assessment of older people. The(More)
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