11.07.13
Patient record standards guidance published
New healthcare record standards have been launched today to ensure a more standardised approach to patient records that follow the patient around the system.
The standards have been developed by a wide range of healthcare professionals, patients, and carers. The work was led by the Royal College of Physicians (RCP) and was commissioned by the Health and Social Care Information Centre (HSCIC)
The guidance includes a list of clinical record headings, including core headings that should be present in all records, and a description of the information that should be recorded.
Professor Iain Carpenter, associate director of the 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 of the 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.”
The organisations who were involved are: Acute and mental health trust medical directors, Association for Clinical Biochemistry, Association for Palliative Medicine of Great Britain and Ireland, Association of British Clinical Diabetologists, Association of Cancer Physicians, Association of Directors of Adult Social Services, Association of Surgeons of Great Britain and Ireland, British Association for Parenteral and Enteral Nutrition, British Association for Sexual Health and HIV, British Association of Audiovestibular Physicians, British Association of Dermatologists, British Association of Oral and Maxillofacial Surgeons, British Association of Otorhinolaryngology, British Association of Paediatric Surgeons, British Association of Plastic, Reconstructive and Aesthetic Surgeons, British Association of Stroke Physicians, British Association of Urological Surgeons, British Cardiovascular Society, British Dietetic Association, British Geriatrics Society, British Infection Association, British Orthodontic Society, British Orthopaedic Association, British Pain Society, British Pharmacological Society, British Psychological Society, British Society for Gastroenterology, British Society for Haematology, British Society for Human Genetics, British Society for Immunology, British Society of Rehabilitation Medicine, British Thoracic Society, Chartered Society of Physiotherapy, Choose and Book clinical leads, Chronic Pain Policy Coalition, Clinical Genetics Society, College of Emergency Medicine, College of Occupational Therapists, Department of Health Informatics Directorate – Patients and Public Clinical Division, EMIS, Faculty of Occupational Medicine, Faculty of Pharmaceutical Medicine, Faculty of Sport and Exercise Medicine, Health and Care Professions Council, In Practice Systems, Intensive Care Society, Local Medical Committee Chairs, National Voices, NHS London, Nursing and Midwifery Council, Nutrition Society, TPP, Renal Association, Royal College of Anaesthetists, Royal College of General Practitioners, Royal College of Midwives, Royal College of Nursing, Royal College of Obstetricians and Gynaecologists, Royal College of Ophthalmologists, Royal College of Paediatrics and Child Health, Royal College of Pathologists, Royal College of Physicians, Royal College of Physicians – Patient and Carer Network, Royal College of Physicians and Surgeons Glasgow, Royal College of Physicians of Edinburgh, Royal College of Psychiatrists, Royal College of Radiologists, Royal College of Surgeons of Edinburgh, Royal Pharmaceutical Society of Great Britain, Society of British Neurological Surgeons, UK Terminology Centre.
To find out more about the new standards, see NHE’s interview with Prof Carpenter.
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