National professional guidance for the structure and content of the clinical records of ambulance patients has been developed by the HIU.
NHS England sponsored a project commissioned through the Health & Social Care Information Centre (HSCIC) to develop national professional guidance for the structure and content of the clinical records of ambulance patients. The project was led by the ambulance services and relevant professional bodies, supported by the Health Informatics Unit (HIU) of the RCP, and the HSCIC.
The information that ambulance care professionals record about the patients with whom they are working is an important clinical record. As the development and implementation of electronic health records gathers pace across the health service, the ability to integrate ambulance information with secondary and primary care patient clinical records becomes increasingly important.
The guidance was designed to meet the needs of patients, reflecting the way that care professionals work across the four nations of the United Kingdom. The project has involved wide consultation including review of existing documentation, clinician and patient workshops and an online questionnaire consultation.
The development of guidance for ambulance documentation built on and is consistent with the standards for the clinical structure and content of patient records, on which the HIU led development, to enable interoperability with records in hospitals and other care settings.
The guidance has been signed off by multiple patient and professional organisations including the Professional Record Standards Body for Health and Social Care.
Association of Ambulance Chief Executives
Association of Directors of Children's Services
Association of Air Ambulances
British Association for Immediate Care (BASICS)
British Cardiovascular Society
British Heart Foundation
British Orthopaedic Association
British Red Cross
Care Provider Alliance
College of Emergency Medicine
College of Occupational Therapists
College of Paramedics
Health and Social Care Information Centre
Independent Ambulance Association
National Ambulance Services Medical Directors Group
National Care Association
Professional Record Standards Body for Health and Social Care
Royal College of Anaesthetists
Royal College of General Practitioners
Royal College of Nursing
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatrics and Child Health
Royal College of Psychiatrists
Royal National Lifeboat Institution
Royal Pharmaceutical Society
The Faculty of Pre‐Hospital Care