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8/6/2019 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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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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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.

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