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Introducing standards for record keeping would enable the quality of information we use to judge clinical outcomes to be improved by creating a robust framework for the gathering of data generated through the day-to-day delivery of clinical care. The RCP in response to this need has produced national, AoMRC endorsed record-keeping standards and is now promoting their uptake.
The value of an inter-operable, clinically relevant patient focussed record - NHS reform is underpinned by the idea that care should cross easily over traditional boundaries. It should be driven by quality and enable greater patient choice and responsibility.
However, poor standards of medical record-keeping in hospital hinder moves towards this. NHS data storage protocols, which depend on multiple applications housed within separate clinical systems, mean that the same or very similar information about patients is often recorded multiple times.
This is not only inefficient, but also makes it more difficult to extract valid aggregate data which is comparable at a national level and has many potential uses, including the evaluation and comparison of clinical outcomes, national audit and retrospective and prospective research.
In response to these concerns, the RCP produced national record-keeping standards which were endorsed by the Academy of Medical Royal Colleges in April 2008. If these are implemented, clinicians will benefit from simpler, structured, navigable records available wherever and whenever needed. Patients will have the opportunity to access their own records, and to move closer to routine self-recording of clinical outcomes.
Standards for record keeping will also allow us to improve the quality of information we use to judge clinical outcomes by creating a robust framework for the gathering of data generated through the day-to-day delivery of clinical care.
The RCP Health Informatics Unit released a vision for patient focussed records and a response to the publication of the Review of Hospital Standardised Mortality ratio:
- Download our Vision Statement below
- Download Response to the Review of Hospital Standardised Mortality Ratio