What we are doing
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.