With funding from Connecting for Health, the HIU has been co-ordinating a project to develop medical profession-wide standards for the content structure of admission, handover and discharge records of patients admitted to hospital (2007-2008). Patient-focused, longitudinal, generic electronic records, which can be customized to the wide variety of contexts in which the patients are seen, fits with the College’s commitment to the needs of the patient.
The process of literature review, drafting, extensive consultation and redrafting has ensured that there has been large scale clinical engagement and specialist contribution to the development of the standards.
The first standards published by the HIU were Generic Medical Record Keeping Standards. These are high level and auditable and are applicable to any patient’s medical record. The twelve standards received formal RCP approval from the Clinical Standards Board meeting in March 2007 and were published in the RCP journal ‘Clinical Medicine’ in August 2007 accompanied by a media launch.
An audit tool based on these standards is being piloted in a number of hospitals and will be available on this website by early Winter.
Generic Medical Record Keeping Standards (PDF 52kb opens in new window)
The second work stream involved developing Record Content Structure Standards for Hospital Practice for
- Admission
- Handover (hospital at night, weekend, consultant team)
- Discharge from hospital
These have been developed to ensure that accurate, valid clinical data can be consistently recorded and retrieved on both paper and electronic format. On April 17th 2008 the Academy of Medical Royal Colleges signed these standards off on behalf of the profession.
Online questionnaires, hospital pilots, feedback from a number of clinicians including over 50 Medical Directors, 30 out of the 37 Medical Royal Colleges and Specialist Societies we contacted for their input contributed to the final standards. A number of workshops were held with clinicians and other key stakeholders. This included a workshop with the RCP Patient and Carer Network that brought a significant perspective to the development of these standards.
These standards we submitted to Connecting for Health and will be submitted to the Information Standards Board for incorporation into the Electronic Patient Record for the NHS in England.
Standards
Approved Admission Proforma Headings and Definitions (PDF 38kb opens in new window)
Approved Handover Documents Headings and Definitions (PDF 65kb opens in new window)
Approved Discharge Summary Headings and Definitions (PDF 48kb opens in new window)
Reports
Hospital Admission online questionnaire results (PDF 214kb opens in new window)
Hospital Admission hospital pilot results (PDF 281kb opens in new window)
Medical Handover and Discharge online questionnaires results (PDF 259kb opens in new window)
Medical Handover and Discharge hospital pilot results (PDF 322kb opens in new window)
Launch date
A formal launch and publications are planned for the Autumn. Templates of admission, handover and discharge records will also be available online as would a clinician's guide.
First stage consensus
A number of stages of consensus was used to get the feedback of working clinicians. The first stage began in July 2006 with a poll we conducted through Doctors.net to gather opinion on standardising the structure of the admission clerking proforma across the NHS.
The poll showed 2:1 in favour of having a standardised proforma with 73% of consultant physicians in agreement. A similar poll was conducted with the fellows and members of the RCP with 86% of consultant physicians agreeing. Both polls had over 1000 respondents.
The respondents who disagreed in the main saw it as a ‘dumbing down’ process involving the use of tick boxes and removing use of free text. This highlighted the need for clarity on the aims of the project – documentation that was completely compatible with current clinical practice but structured to maximise the benefits of standardised clinical information.
Royal College of Physicians poll results (PDF 33kb opens in new window)