Professional guidance on the structure and content of ambulance records

National professional guidance for the structure and content of the clinical records of ambulance patients has been developed by the HIU.

What we are doing

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.

Who's involved

Organisations

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

National Voices

NHS England

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

What we have produced

National professional guidance for the structure and content of the clinical records of ambulance patients has been developed by the HIU.