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Transcript of Clinicians Guide Part 1 Context
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Informa
tionGovernance
A Clinicians Guide to Record Standards Part 1:
Why standardise the structure
and content o medical records?
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Contents
Page 3
A guide or clinicians
Pages 4 and 5
Why have standards or the structure and
content o medical records?Pages 6 and 7
What are standards or the structure andcontent o medical records?
Page 8
The Electronic Patient Record
Pages 10 and 11
Where are we now?
Pages 12 and 13
What does it mean or me?
Page 14
What is happening next?
Page 15
Where can I get more inormation?
Page 15
Reerences
Published by the Digital and Health Information Policy Directorate October 2008. Gateway number 10508.
Developed by the Health Informatics Unit,Clinical Standards Department, Royal College of Physicians
Project funded by NHS Connecting for Health
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A
CliniciansGuide
Standardisingthestructureandconten
tofmedicalrecords
This good practice guide has been produced to inormhospital doctors about current developments in
medical record keeping standards or the ElectronicPatient Record. It describes why standards are neededor the structure and content o medical records andhow their introduction will aect our work.
The record standards, approved or all specialties by theAcademy o Medical Royal Colleges, are published inA Clinicians Guide to Record Standards - Part 2:
Standards or the structure and content o medical recordsand communications when patients are admitted to hospital.
The standards should be used or all hospital patient records.
The guides can be downloaded rom the RCP website:www.rcplondon.ac.uk/clinical-standards/hiu/medical-records
Copies can be also ordered rom the DH and NHS CFH DigitalInormation and Health Policy Directorate.Go to: inormation.connectingorhealth.nhs.uk> Digital Health Inormation Policy > Booklet
A guide or clinicians
Page 3
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Why have standards for thestructure and content ofmedical records?
The principal purpose o medical records and medical notes is torecord and communicate inormation about patients and their care.
I notes are not organised and completed properly, it can lead to
rustration, debate, clinical misadventure and litigation.
Originally kept as an aide-memoire, medical records are now used not only
as a comprehensive record o care but also as a source o data or hospital
service activity reporting, monitoring the perormance o hospitals and or
audit and research. Many o the causes o inaccurate clinical coding o thissecondary data are rooted in the quality o medical notes.1,2
The quality o medical record keeping in the UK is highly variable across
the NHS.3 The layout o admission, handover and discharge proormas
is very dierent between hospitals and clinical departments and many do
not use proormas. This variability is largely because doctors learn how
to take a medical history by apprenticeship rather than the application
o a standard record structure. However research evidence shows that
structured records have benecial eects on doctor perormance and
patient outcomes.4
The constant drive to improve the quality and saety o medical practice
and hospital services and the increasing expectations and costs o medical
care means the structure and content o the clinical record is becoming
ever more important.5 Implementation o electronic patient records in the
NHS critically increases the importance o structured records.
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Implementation o electronic
patient records in the NHScritically increases the importanceo structured records
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What are standards for thestructure and content ofmedical records?
Record keeping standards can be sub-divided into two categories:generic standards or good practice and specifc standards to defne
the structure and content in specifc clinical contexts.
Generic standards
Generic medical record keeping standards apply to all medical notes
and address the broad requirements or clinical note keeping. Several
Medical Royal Colleges and Specialist Societies and the medical deence
organisations have published their own reiteration o the GMCsrequirement or good medical practice. The Health Care Commission
inspections and the NHS Litigation Authority Risk Management Standards
include requirements or medical record keeping.
Good Medical Practice
providing good clinical careIn providing good clinical care [doctors] must:
keepclear,accurateandlegiblerecords,reportingtherelevant
clinical ndings, the decisions made, the inormation given to
patients, and any drugs prescribed or other investigation or
treatment
makerecordsatthesametimeastheeventsyouarerecording
or as soon as possible aterwards
www.gmc-uk.org/guidance/good_medical_practice/
good_clinical_care/index.asp
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Standards or structure and content
Standards are also needed so that records are structured appropriately and
clinical inormation is recorded in the right place. Content standards apply
to the ormat and denition o what is recorded in this structure.
Examples include:
A unique patient identier (NHS Number in England and Wales,
CHI in Scotland) must be used in all medical records and on all
communications. Use o the NHS number is increasing, particularly
in general practice, but most hospitals rely partially or totally on the
hospital number as the unique Patient ID.
Common identiers or clinicians, researchers and organisations (such as
the GMC number or doctors), both within and outside the NHS.
Standard denitions or demographic, organisational andadministrative inormation are contained in the NHS data dictionary
www.datadictionary.nhs.uk. The Dictionary standardises the data that
are extracted rom the paper medical records and patient administration
systems so that they can be used or central returns,
in particular Hospital Episode Statistics. In England, the data dictionary
now also contains a number o denitions or data used in audits.
However where the same piece o inormation is used in more than
one dataset, the denition o that data item is not always the same in
the dierent datasets.
Clinicalinformationforcentralreturnsisextractedfrompatientrecords
and coded in ICD-10 or diagnosis and OPCS-4 or procedures. ICD-
10 and OPCS-4 are statistical classications. These do not have the
comprehensiveness, depth or fexibility needed to apply to medical
records that are used by clinicians in every day practice.
SNOMED-CTisaverycomprehensiveinternationalthesaurusofcoded
terms that will be introduced in the NHS. However the detailedguidance on how it will be used in day-to-day electronic records is not
yet ully developed.
Diseaseorinterventionspecicdatasetshavebeendevelopedby
specialist societies. However they requently contain dierent denitions
or the same clinical condition and coverage o the clinical encounter
is ad hoc. With the development o the electronic patient record there
is now an urgent need to standardise the structure and content o the
clinical inormation recorded and communicated.
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The Electronic Patient RecordThere are two principal components to the electronic patient record
programme or hospitals in England: the Summary Care Record
and Detailed Care Records.
Summary Care Record (SCR)The Summary Care Record will initially contain only basic inormation such
as major diagnoses and procedures, current medications, adverse reactions
and allergies. It is the single common set o clinical inormation about
patients which will be accessible to all authorised health care proessionals
treating them anywhere in the NHS in England. It is being constructed
rom the data in primary care records and is currently being rolled out
across the NHS.
Detailed Care RecordsOver the next ew years, as the Electronic Patient Record system develops,
NHS organisations which normally work together in a local area such
as hospitals, clinics and GPs - will develop and begin to link and access
detailed electronic records or each patient. Early adopter Trusts are
currently (2008) implementing the rst hospital versions o these systems
while many General Practices have long established electronic record
systems. It is intended that medical records will become increasingly
paper ree and interoperable so that the validity o the data held will be
preserved between systems and locations.
Clinician and patient involvementStructure and content standards are essential or ensuring that clinical
data can be reliably stored, retrieved and shared between inormation
systems. The standards must be based on proessional consensus that
refect best clinical practice, and then implemented into inormation
systems by the IT proessionals. Patients must be involved in all stages o
development. The standards should acilitate not hinder the process o
writing, communicating and retrieving clinical inormation, so that care is
saer and more ecient.
There is substantial risk i the proession does not speciy what these
standards are. I we do not, then implementation will refect rst the
technical standards o existing computer systems (generally developed
around administrative and nancial requirements) and then require clinical
practice to change in order to accommodate the way the computersystems have been designed to work. This would threaten the quality,
saety and eciency o clinical practice.
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Standards must be based onproessional consensus and
refect best clinical practice.And patients must be involvedin all stages o development.
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Where are we now?Generic standards developmentThe Health Inormatics Unit (HIU) at the Royal College o Physicians,
London, reviewed standards published by the medical Royal Colleges,
specialist societies, GMC and medical deence organisations, and in theresearch literature. Following wide consultation with the proession,
12 generic medical record standards were published in 20073
(www.library.nhs.uk/GuidelinesFinder/ViewResource.aspx?resID=270611).
The generic standards apply to any patients medical record. Several o
the standards, such as date and time o each entry, will be automatically
recorded in electronic records. Others such as the requency o record
entries are designed to be fexible and pragmatic.
The Department o Health and NHS Connecting or Health have
incorporated the generic standards into the Inormation Governance
Toolkit (www.igt.connectingorhealth.nhs.uk). An audit o medical records
against the standards can be used by Trusts to demonstrate compliance
with NHS Litigation Authority Risk Management Standards and or
inspections by the Health Care Commission. An audit tool or audit o
records against the standards will be available on www.rcplondon.ac.uk/
clinical-standards/hiu/medical-records during 2009.
The Generic Medical Record Keeping Standards for hospital patients
are published inA Clinicians Guide to Record Standards Part 2:
Standards for the structure and content of medical records and
communications when patients are admitted to hospital available
at www.rcplondon.ac.uk/hiu
Development of standards for structure
and contentNHS Connecting or Health have unded a project co-ordinated by
the Health Inormatics Unit o the Royal College o Physicians, to
develop medical proession-wide standards or the recording and
communicating o clinical inormation when patients are admitted to
hospital. The process o literature review, drating, extensive consultation,
redrating and piloting (see fgure) ensured that there was large scale
clinical engagement and contributions by the medical Royal Colleges
and specialist societies to the development o the standards. Over threethousand doctors responded to the consultation on admission record
headings, and 91% agreed that there should be structured documentation
across the whole NHS.
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The medical Royal Colleges and specialist societies conrmed that the
high-level headings or the structure o admission records and handover
and discharge communications were t or purpose within their specialty.
There is some inter-specialty variation in the inormation that should berecorded in sub-headings. For example, the Royal College o Psychiatrists
and the Royal College o Paediatrics and Child Health have stated that
their specialties require inormation which is substantially dierent and
additional to the proposed headings. However both Colleges conrmed
that this additional inormation can be largely accommodated within the
generic structure proposed.
In April 2008 the Academy o Medical Royal Colleges approved thesestandards or all medical and surgical hospital admission records and
handover and discharge communications. They were then delivered to
NHS Connecting or Health. These standards can also be used to structure
current and new paper based record proormas.
The structure and content standards for admission records and
handover and discharge communications of hospital patients are
published inA Clinicians Guide to Record Standards Part 2:
Standards for the structure and content of medical records and
communications when patients are admitted to hospital
available at www.rcplondon.ac.uk/clinical-standards/hiu/
medical-records
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dra
ft
consu
lt
revi
se
agree
de
liver
sig
n
Review of Evidence by Royal College of Physicians Health Informatics Unit
Production of Medical Record Content Standards Initial Draft
Consultations / Questionnaires with Practising Clinicians and Patient Carer Network
Workshops with Informed Practitioners, Patient Carer Network and Key Stakeholders
Email / Telephone Consultations with Medical Royal Colleges and Specialist Societies
Revision of Medical Record Content Standards draft by Royal College of PhysiciansHealth Informatics Unit
Royal Colleges and Specialist Societies Nominees confirm requirements met
Medical Record Content Standards
Academy of Medical Royal Colleges - sign off by College Presidents
Connecting for Health and Information Standards Board
Figure: The process o developing the Medical Record Structure andContent Standards. The standards were approved by the Academy oMedical Royal Colleges on 17th April 2008
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What does it mean for me?With this document, the Department o Health is publishing the
agreed Generic Medical Record Keeping Standards and the high
level structure and content standards or admission, handover and
discharge6
. All clinical records, electronic and paper, should bestructured using these headings.
Example templates or admission, handover and discharge proormas are
available or download on www.rcplondon.ac.uk/clinical-standards/hiu/
medical-records and can be used to create paper proormas that can be
customised or use by individual hospitals and Trusts.
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The benefts o structure and content standards
Standardisationofcontentwillimprovesafetybyreducing
opportunities or ambiguity or omission o data.
Paperproformascanbedevelopedusingthesestandardswith
condence that they are likely to refect best practice.
Structuringrecordsinthiswaywillhelptoimprove:
ease and accuracy in communication o clinical inormation,
the quality and saety o clinical practice and
the accuracy o clinical coding.
Whenjuniordoctorsmovefromonehospitalordepartment
to another, they will not need to amiliarise themselves with
new document structures.
Clinicalinformationinelectronicrecordswillberecorded
once, and made available when needed, thus improving
eciency and saving time.
Implementationofnewclinicalinformationsystemswill
be simplied, as the systems will all be built on the same
proessionally developed and agreed standards or clinical
structure and content.
Patientsandcarerswereinvolvedinthedevelopmentof
the standards and their considerations will become better
embedded in clinical practice.
TheRoyalCollegeofGeneralPractitionerswasconsulted
and GPs took part in the piloting o the discharge standards.
Discharge summaries based on these standards should deliver
the inormation that they want and need.
Nationalauditsshouldbeeasiertoconductusingcomparable
data rom across the country.
Routineclinicaldatawillbettersupportresearch.Both
prospective trials and retrospective epidemiological studies
will be easier and more cost eective to carry out.
Itislikelythatrevalidationwillincludeanevaluationof
clinical perormance with some evidence rom medical notes.
Structuring notes using the standards will contribute to a air
evaluation.
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What is happening next?A series o workshops around the country are developing the
standards and defnitions or the more detailed clinical content o
admission records, and handover and discharge communications.
The development o standards or outpatient records, medicalcontinuation notes and operation and procedure notes will ollow.
So also will the process or nursing, midwiery and the Allied
Health Proessions to develop their record structure standards.
Where clinical content is developed locally, it will be necessary to ensure
that it is compatible with practice across the NHS in England. This process
is intended to avoid locality specic variations, errors or omissions being
imposed inappropriately across the whole health service and to ensure
that the views o as many practising doctors as possible are gathered.
The process, called Clinical Assurance by NHS Connecting or Health, will
ollow the same general process as used by the RCP HIU to develop the
high level headings or admission, handover and discharge. The goal
is to achieve consensus so that implementation does truly refect best
practice and establishes the best possible basis or smooth adoption o the
structured records by practising doctors across all hospitals and services.
It is specically not intended to limit the content and constrain innovation
and development, nor is it intended to create a dumbed down approach
to medical practice.
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Where can I get moreinformation?I you would like more inormation on any o these matters you can go
to www.rcplondon.ac.uk/clinical-standards/hiu/medical-records
and www.connectingorhealth.nhs.uk/systemsandservices/inogov
You can also contact the Royal College o Physicians Health Inormatics
Unit on [email protected]
References
1 Royal College o Physicians, 2007. Hospital Activity Data. A guide or
Clinicians. London.
2 The Audit Commission, 2008. PbR Data Assurance Framework
2007/2008: Findings rom the rst year o the national clinical coding
audit programme. London.
3 Carpenter I, Bridgelal Ram M, Crot GP, Williams JG. 2007. Medical
records and record-keeping standards. Clinical Medicine:7:(4);328-331.
4 Mann R, Williams J. 2003. Standards in medical record keeping. Clinical
Medicine; 3:329-32.
5 Pullen I, Loudon J. 2006. Improving standards in clinical record-keeping.
Advances in psychiatric treatment;12:280-6.
6 Department o Health 2008. A Clinicians Guide to Record
Standards Part 2: Standards or the structure and content o medical
records and communications when patients are admitted to hospital.
Department o Health, London.
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NHS Connecting for Health is supporting the NHS to introduce new computer systems and services.
This is known as the National Programme for IT. It will help the NHS deliver better, safer care for patients.
Crown Copyright 2008 Ref: 4275b
This document is printed on paper made rom recycled
fbre and fbre rom sustainably managed orests.