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Professional approach to digital record standards. Using the core clinical model. Presented by Nick Booth Clinical Director - Information Standards Delivery. Outline. The structures of HSCIC and NIB How will information standards be created

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professional approach to digital record standards

Professional approach to digital record standards

Using the core clinical model

Presented by

Nick Booth

Clinical Director - Information Standards Delivery

outline
Outline
  • The structures of HSCIC and NIB
  • How will information standards be created
  • What is the role of health and social care (The PRSB)
  • AoMRC clinical record standards
  • Strategic considerations – the core clinical model
the health and social care information centre
The Health and Social Care Information Centre

HSCIC collects, analyses and publishes national data and statistical information for commissioners, analysts and clinicians. It also provides systems and infrastructure at a national level and sets standards for health and social care.

HSCIC is an executive non-departmental public bodyof the Department of Health

slide5

NHS England - commissioning on behalf of the ISCG

NIB

National Information Board

The role of the ISCG is to commission services within an agreed strategic framework and then to monitor their delivery against set objectives

structures as at 01 april 2014
Structures as at 01 April 2014

Social Care

Public Health England

National Information Board

Standardisation Committee for Care Information

INFORMATION STANDARDS DELIVERY

PRSB

UKTC

Classifi-cations

Clinical Models

PCISS

Data Dictionary

HSCIC

slide7

Collaborative design

Information Standards Delivery

SCCI

NHS England

PHE

DH-SC

others

Monitor

CQC

Research

NMC, GMC,

Regulators

Social carers

NICE

work of pciss
Work of PCISS
  • National Laboratory Medicines Catalogue (PCDIP)
    • Pathology Catalogue development and implementation programme
  • Ambulance Clinical Documentation Project
  • AoMRC multipurpose message
  • MyCareRecord
  • PRSB – management of the HSCIC – PRSB relationship
foundations for coherent record and data standards
Foundations for coherent record and data standards

GP2GP

Record Keeping Standards

- AoMRC 2008

Clinical Documentation Standards (CDGRS)

- Royal College of Physicians / AoMRC 2013

Experience of “Clinical Content” in National Programme for IT

slide12

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

Who participated?

slide13
And...

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

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

and who signed them off
And who signed them off..

British Thoracic Society

Chartered Society of Physiotherapy

Chronic Pain Policy Coalition (CPPC)

Clinical Genetics Society

College of Emergency Medicine

College of Occupational Therapists

Faculty of Occupational Medicine

Faculty of Sport and Exercise Medicine

Intensive Care Society

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

(RCOG)

Royal College of Ophthalmologists

Royal College of Paediatrics and Child Health

Royal College of Pathologists

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

The Royal College of Surgeons of England

Royal Pharmaceutical Society (RPS)

Society of British Neurological Surgeons

Association for Clinical Biochemistry

Association for Palliative Medicine of Great Britain &

Ireland

Association of British Clinical Diabetologists

Association of Cancer Physicians

Association of Surgeons of Great Britain and Ireland

British Association for Parenteral & Enteral Nutrition

British Association of Audiovestibular Physicians

British Association of Dermatologists

British Association of Otorhinolaryngology (Ears, Nose

and Throat) (ENT – UK)

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 Psychological Society

British Society for Gastroenterology

British Society for Haematology

British Society for Genetic Medicine

British Society for Immunology

the core clinical headings and model
The Core Clinical Headings and Model

http://www.rcplondon.ac.uk/resources/standards-clinical-structure-and-content-patient-records

core clinical model
Core Clinical Model
  • These are the key core headings which are used to convey meaningful clinical information in a structured fashion
  • Information under each heading can be coded or left in narrative form
core headings
Core headings

1. GP Practice

2. Patient Demographics

3. Participation in research

4. Clinical Summary

5. Reasons for Contact

6. Presenting complaints or issues

7. Family History

8. Diagnoses

9. Procedures

10.Assessment Scales

11. Investigations and Results

12. Problems and issues

13. Patient and carer concerns

14. Medications and Medical Devices

15. Allergies and adverse reaction

16. Safety Alerts

17. Plan and Requested Actions

18. Information given

19. Legal information

20. Person Completing Record

core model can facilitate
Core model can facilitate?
  • Communication
  • Information reuse
    • Clinical Audit
    • Commissioning
    • Choice
    • Continuing Professional Development
    • Research

Confidence and Quality

information movement
Information Movement

Clinical Message

slide21

Core Information

Admission

Referrer

The core information is enriched at each step

By agreeing a ‘core’ information standard we can allow individual systems to share information

This ‘core’ information can then be saved on each individual system

Handover

Discharge

slide22

Newcastle Discharge

  • Venogram done 13/6/12
  • Arrived on system 13/6/12
apply the core clinical headings to extract key clinical information from
Apply the core clinical headings to extract key clinical information from...
  • Hospital eDischarge Summary (eDS)
  • Nursing Documentation
  • Emergency Department eDS
  • Outpatient Letters
  • Handover Documents
  • Referral Letters
  • Transfer Documentation
discussion
Discussion

Standards for the clinical structure and content of patient records

http://www.rcplondon.ac.uk/projects/healthcare-record-standards