British Geriatrics Society

Development of standardised clinical reports by the HIU

The Health Informatics Unit (HIU) is part of the Clinical Standards Department at the Royal College of Physicians (London).

HIU has been dedicated to developing patient-focused records standards and guidelines since 2001. The HIU celebrated its tenth anniversary in September 2011, with an event which reviewed the past ten years and looked towards the future for health informatics in the NHS. The main aims of HIU are to:

• develop standards for recording and communicating information about patients
• apply standards to operational records to improve the validity and utility of patient data
• structure the records so that the information can be incorporated into electronic records, shared with other healthcare providers and analysed with confidence.

Why are standards for structure and content needed?

Standardised healthcare records would enable one to:

• facilitate continuity of care within and between multi-professional and multi-site teams
• support those professionals to achieve the best available evidence at point of care decisions
• monitor for critical events and trends, and to avoid error
• assist patients in understanding their own health, sharing in healthcare decisions, and engaging with self-care
• support quality improvement and professional learning, and inform those managing the health service including service planning, commissioning and accounting for resource utilisation
• underpin population health and clinical research.

Developing and implementing professional structure and content standards

Effective implementation of standardised, structured, patient focused records requires strongly led culture change, embraced by all professionals and other health service staff. They are prerequisites for safe, high quality care and for the efficient migration from paper to electronic patient records. To achieve this acceptance, record content standards must reflect clinical practice, be evidence based, developed through consensus and be professionally endorsed. The standards should be practical, feasible and also include clear guidance on the care process for which it is intended, for example, for admission clerking of patients admitted to hospital.

Developments to date

To date, the unit has successfully led the Clinical Documentation and Generic Records Standards (CDGRS) Project Phase 1, which saw the development and publication of evidence and consensus based professional structure and content standards for admission, handover and discharge records. Generic Medical Record Keeping Standards for physicians that are applicable to any patient’s medical record were developed 2. Twelve standards were approved as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges in April 2008. The standards, in summary, contribute to maximising patient safety and quality of care (through improved completeness of documentation by clinicians and improved clinical performance), to support professional best practice, and they enable compliance with Information Governance and NHS Litigation Authority Clinical Negligence Scheme for Trusts standards. They have been received with wide acclaim and are now referenced in national regulatory and professional documents and policies across the NHS.

The CDGRS has recently also been involved in producing a report proposing the establishment of an independent professional body that will have the responsibility for overseeing the development of standards for the structure and content of health and social care records3. The report was prepared by a Joint Working Group commissioned by the DH Informatics Directorate and chaired by Dr Charles Gutteridge, National Clinical Director for Informatics.

Referrals

The next phase of the CDGRS project is to develop standards for the structure and content of referrals. Referrals are an extremely important component of the patient journey and associated information flow. Specifically, referrals must meet the requirements of the referring clinician (most commonly the GP) and also requirements of the receiving clinician or clinical service. There was a recent workshop on 5th April at the RCP(L) to examine the core headings of referral forms (see table 1). Several academic institutions and Royal Colleges were represented at the workshop. Throughout the process of drafting these standard headings, the HIU has ensured that there has been large-scale clinical engagement and specialist contribution to the development of the standards. This has included extensive consultation with all the medical Royal Colleges, specialist societies, patients and carers, and with acute and mental health trusts.

The principles that underpin the core clinical headings are:

1. They are headings of the highest priority for early introduction into electronic health records (HER)
2. They give a clear summary of the patient’s clinical state
3. They apply to the patient focused record and should be accessible in any care context as they form the basis of clinical record in relation to any episode or contact of care
4. Some items are static; some are changeable: The mechanism for recording change is through the record, by noting the date and time of new entries
5. Change over time is through sequential, dated entries
6. They should appear in all clinical records, though they need not necessarily record data every time they appear. Completion is ‘optional’ in that they are only completed if there is data to record
7. Simplicity is essential

While most of these core headings would be welcome for geriatric medicine referrals, for both geriatric and general medicine, I believe having a core heading of social history/circumstances is important. I appreciate that some of the other core headings may capture this but I think this merits a core heading in itself. This information is vital not only for patient management but also for patient flows e.g. discharge planning, destination, community care and so on. Moreover, the concept of structured scales is very welcome; this will compel the user to document them.

Further workshops and consultations are planned for later this year to refine the standards and produce guidance for the referral forms. The BGS is fortunate in having one of its members, Professor Iain Carpenter, as Associate Director of HIU, thus ensuring that our views and requirements are duly considered.

Table of Core Headings for Referral Forms

DEMOGRAPHIC DETAILS

REASONS FOR CONTACT
This would include reasons for admission, referral, attendance or encounter. The health problems and issues experienced by the patient resulting in their hospital admission, e.g. chest pain, blackout, fall, a specific procedure, investigation or treatment.

PRESENTING ISSUE
The patient reported symptoms and issues in relation to the current admission / referral / contact.

DIAGNOSES
This section includes all diagnoses.

OPERATIONS AND PROCEDURES
Relevant therapeutic operations and procedures, including any complications and adverse events arising during the procedure

STRUCTURED SCALES
Standardised scales that indicate, for example, severity of illness, physical and cognitive function, Glasgow Coma Scale (GCS), etc.

INVESTIGATIONS AND RESULTS
The relevant investigations performed and their respective results, where present.

CURRENT PROBLEMS AND ISSUES
Problems requiring health or social care services or carer attention.

PATIENT AND CARERS CONCERNS
The record of the patient’s comments related to their perceptions of their symptoms, their wishes and goals related to their health and their perceptions of their anticipated treatment (which may influence treatment).

MEDICATIONS
A list of all prescribed or non-prescribed (e.g. over-the-counter) current medications.

ALLERGIES AND ADVERSE REACTIONS
Allergies, drug allergies and adverse reactions.

RISKS AND WARNINGS
Significant risk of an unfavourable event occurring, patient is Hepatitis C +ve, MRSA +ve, HIV +ve etc. Any clinical alerts, vulnerable adult / child

MANAGEMENT PLAN
Including planned investigations and treatment for a patient’s identified conditions and priorities.

INFORMATION GIVEN TO PATIENT
Information and advice given directly to the patient and/or authorised representative.

RELEVANT LEGAL INFORMATION
Includes mental capacity, advanced decisions about treatment, lasting and enduring power of attorney or deputy and organ donation. To include the location of the relevant documents. The 4 nation descriptions may vary.