New standards designed to ensure that health records are properly named and indexed have been published by the Professional Record Standards Body (PRSB).
Developed in partnership with the Royal College of Physicians (RCP) Health Informatics Unit (HIU), the standards ensure that records can be easily found when needed, particularly in an emergency.
Currently information about a person’s previous care may be held on a number of IT systems, with trusts also scanning historical paper records into digital files.
This can be hard to navigate and difficult to retrieve from the system, increasing the risk of treatment errors.
Dr Neelam Dugar, consultant radiologist at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and who led the project for the PRSB, said: “This new standard will generate consistency throughout the NHS, by ensuring documents are correctly named and can be easily located in online systems.
“For example, if a clinician needs access to a patient’s previous x-ray results, these can all be found under ‘radiology reports’, rather than a range of different places. Ultimately this will make care better and safer for patients, by ensuring easy access to important information.”
As well as enabling clinicians to compare and contrast previous test results, scans and other information, patients won’t have to repeat complicated medical histories.
It is also hoped the standards will help reduce the risk of data getting lost.
The PRSB is the organisation tasked with developing standards for digital health and care records.
It has published a number of standards this year, including those aimed at community pharmacies and GPs and clinical referrals.
24 December 2018 @ 12:20
Looking at the Scottish list (*why* no English or UK-wide publication on the PRSB website?), I’m not sure how useful it will be for GP records – unless there is a means of linking more information to the Codes.
GPs receive a large number of outpatient and discharge letters: it really is necessary to know to tag letters with their provenance – consultant, speciality, hospital, date – & preferably some indication of content.
Results of investigations are, as often as not, contained in letters as part of communication – & not freestanding. (Remember Larry Weed’s comments?)
This is obviously an advance – I hadn’t appreciated the apparent lack of any form of organisation in hospital EHRs – but if this is intended to be a Standard for primary as well as secondary care, I do wonder whether anyone from primary care has been involved… & if they have, who they were!
15 December 2018 @ 14:56
Where are the links to the lists? I found a Scottish list and a quick search elsewhere brings up an English list. https://termbrowser.nhs.uk/?perspective=full&conceptId1=999000391000000109
I presume the plan is to merge these into one SNOMED CT RefSet?