In the order indicated in A Clinician's Guide to Record Standards - Part 2: Standards for the structure and content of medical records and communications when patients are admitted to hospital (Academy of Medical Royal Colleges, October 2008):

• GP Details
• OtherContact Details
• Patient Details
• Admission Details
• Discharge Details
• Hospital Stay Responsible Consultants List
• All Current Diagnoses At Discharge
• Other Significant Problems At Discharge
• Operations And Significant Procedures
• Reason For Admission And Presenting Complaints
• Mental Capacity
• Advance Decisions And Resuscitation Status
• Allergies And Adverse Reactions
• Risks And Warnings
• Clinical Narrative
• Significant Investigations And Results
• Significant Treatments And Changes Made To Treatments
• Measures Of Physical Ability And Cognitive Function
• Current Medications
• Medication Recommendations
• Stopped Medications
• Hospital Advice Recommendations And Future Plan
• GP Advice Recommendations And Future Plan
• Community And Specialist Services Advice Recommendations And Future Plan
• Information For Patient
• Information Given To Patient And Or Authorised Representative
• Patients Concerns Expectations And Wishes
• Results Awaited
• Person Entering Data
• Person Authoring Data
• Person Verifying Data
• Distribution List
• Distribution Record