11 July 2013

Formally launched today, the latest version of healthcare record standards will inform the development of electronic health records by both clinicians and industry. This guidance can help to meet the Secretary of State for health’s challenge to the NHS to ‘go paperless’ by 2018. By following these standards for the structure and content of patients’ healthcare records, the NHS can improve patient care and the quality of data available for measurement of whole system performance, and stop reinventing the wheel.

Standards for the clinical structure and content of patient records have been developed by healthcare professionals from multi-disciplinary backgrounds, patients, carers and health information technology specialists in a programme of work led by the Royal College of Physicians (RCP) and commissioned by Health and Social Care Information Centre (HSCIC).

At the core of the healthcare system is the patient’s clinical record – it is the record of patient/clinician dialogue. Resulting decisions and actions taken stem from the information held in a patient’s healthcare record. Currently, patients have to give information and details at every stage of their care, because the patient record does not follow the patient around the system adequately.

The electronic patient record (EPR) will be the key to unlocking significant change and driving progress. If a patient’s information and details can be accurately recorded at a singular point – ie during the dialogue with the clinician – then the need to repeat themselves each visit will be eliminated. Collecting patient data in this way will deliver improved patient care, high quality patient experience and greater efficiency in terms of management and research in healthcare.

For clinical information to be recorded in a way that can be shared and reused it must have a standardised structure and these new standards provide this structure. Implementation of these record standards will help to bring about a system where a patient’s record can follow them as they move between care settings, whether across primary, secondary, or mental health and community care. Different headings apply in different settings; clinicians don’t need to use all the headings every time. These standards have been developed to reflect the way patients and clinicians work together.

The guidance provides a set of generic standards for clinical records.  They consist of a list of clinical record headings and a description of the information that should be recorded under each heading.  It also provides reference to the record(s) or communication(s) in which they should be used.  Finally, it also lists those headings that are the core clinical headings, those headings which should be present as a priority in all electronic patient record systems.

Professor Iain Carpenter, Associate Director, RCP Health Informatics Unit (HIU) said: “These record standard headings represent the requirements of patients and clinical professionals for care records.  The Department of Health (DH) and NHS England set the goal of a ‘paperless’ NHS by 2018. If there is to be any chance of achieving this ambitious challenge, it will have to be based on integrated EPRs holding information recorded at the point of care.  These standards are the clinical basis for those technical solutions.”

Professor Terence Stephenson, Chair, Academy of Medical Royal Colleges (AoMRC) said: “Patients should receive a level of care that allows both their hospital-based doctor and their GP to have a clear, common understanding of events impacting their health – without the patient themselves having to act as messenger or interpreter. The standards for patient records have been approved by all Academy members. It lays a strong foundation for electronic health records which will not only improve the patient experience, but will also improve safety and efficiency. As with all standards, the real benefit comes in their implementation, and I strongly urge all colleagues to do whatever they can to support their use.”

Dr Mark Davies, Director Clinical and Public Assurance, HSCIC said: “Clinical records are an intrinsic part of the care process.  If the data that are derived from them is to be as complete and accurate as possible, it is important that they are built on professional ownership. The HSCIC supports the essential role that the clinical community plays in maintaining and developing the underlying record keeping standards that will ensure our information accurately reflects the care delivered. Data quality will be at its best when it is relevant to the clinical teams delivering care and assured by them. In the future patients will also have an important part to play in assuring the records and so these standards are an essential foundation to build an information landscape that reflects more accurately what is actually happening in the NHS.”

Mike Farrar, Chief Executive, NHS Confederation said: “EPRs are the way forward for the NHS. If we can get the right system in place, the paybacks will be immediate, both for patients and the staff who care for them. The NHS has done a lot of work to switch to a paperless service with impressive results, but such initiatives are patchy. What we really need is a programme that joins up the whole system, one that is accessible no matter which NHS service is treating you and one that frees up more clinicians' time and patients' time to focus on care.”

Suzie Hughes, Chair, RCP Patient Carer Network (PCN) said: “The new healthcare record standards will be life changing for both staff and patients, especially those patients with long term conditions and comorbidity. Following the points raised about record keeping within the Francis report, this is an essential piece of work. The need to repeatedly take a patient’s history will be removed and safety standards in record keeping will be raised. In an ever-changing NHS landscape the need for patients to have a patient record that travels with them across organisations, recording the complete patient journey will be life changing for many patients and staff alike.”

 

Notes to editors

For further information contact Hannah Bristow, RCP Clinical Standards communications officer, Hannah.Bristow@rcplondon.ac.uk, 020 3075 1447, 07584 303 784 or visit http://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient-records

The CDGRS programme has also produced further technical information and more detailed information on medication and medical device records
http://www.rcplondon.ac.uk/resources/standards-admission-handover-discharge-outpatient-and-referral-technical-annex
http://www.rcplondon.ac.uk/resources/medications-and-medical-device-records.

The HSCIC was established on April 1 2013 as an Executive Non Departmental Public Body (ENDPB). It is England’s trusted data source, delivering high quality information and IT systems to drive better patient services, care and outcomes. Its work includes publishing more than 130 statistical publications annually; providing a range of specialist data services; managing informatics projects and programmes and developing and assuring national systems against appropriate contractual, clinical safety and information standards.

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