Testing the clarity of record standards with clinicians
PRSB recommends how to make clinical structure and content of patient records clearer
The PRSB has user-tested standards for the clinical structure and content of patient records, including admission, handover, discharge, referral, outpatient and core headings. These are known as the Clinical Documentation and Generic Record Standards (CDGRS).
The standards are patient-centred, evidence and consensus based. They have been developed with multi-professional and patient involvement throughout. They are endorsed by the Academy of Medical Royal Colleges (AoMRC) and have been adopted by the PRSB.
The purpose of the user testing project was to identify, and where possible in the time available, resolve any ambiguity or lack of clarity in the headings or their clinical descriptions. The Health Informatics Unit (HIU) of the Royal College of Physicians led development of the CDGRS standards and was appointed by the PRSB to lead this project.
The Health and Social Care Information Centre commissioned our report. Following testing with record users, it recommends how to clarify important headings and clinical descriptions that are considered to be ambiguous or unclear.