28 July 2017
Outpatient letter standards
New PRSB standards for digital outpatient letters allow clinical information to be recorded, exchanged and accessed consistently across care settings.
As more care and a wider range of specialist services are delivered out of hospital, the importance of well-structured outpatient letters is essential to good communications between clinicians and patients. They are the main method of contact and communication between hospital staff and GPs and communicate to the patient a record of the consultation and decisions. They are often the sole record of the consultation held by the outpatient department and hospital.
These standards will improve continuity of care by helping clinicians to communicate relevant information more quickly, reducing transcription errors by enabling re-use of key data in the GP system and producing better information for audit and research by carrying information in coded format, where appropriate.
The PRSB is publishing the outpatient letter standards in draft form while it undergoes endorsement by our relevant member organisations. The standard may change in its final form but we expect any changes to be minor. Providers may begin incorporating the standard into their systems but should be aware there may be minor amendments in due course. The final version will be published on the PRSB as soon as it is available this autumn.
- Clinical headings and information model
- Medications and medical devices information model
- Final report
This guidance sets out issues identified during the project which relate to the implementation of the headings and sub-headings. They are not intended to be comprehensive, but just those issues identified at this stage. It is expected that further guidance will be produced from the experience of initial implementations.
Outpatient letter examples
Clinicians from different specialties were asked to compose example outpatient letters to represent different types of appointments (initial and follow-up, doctor, and AHP led clinics) to demonstrate how the information might be best structured. The letters were quality assured by the PRSB assurance committee.
The standard does not specify the layout or appearance of the discharge, which is for local determination, and therefore the examples are not intended to be used as templates. For the people creating templates in their organisation, please read the implementation guide
The project approach
During the project phase we consulted widely with patients and service users, carers, GPs and primary care professionals, outpatient clinic health professionals and system vendors to ensure that the outpatient letter standards meet the needs of the authors and recipients, and are easy for outpatient clinics and vendors to implement in IT systems.
The focus of the project was on:
- Identifying what information GPs and patients require in outpatient letters and what information it would be preferable to have in a coded form.
- Identifying what structured (and coded) information it is feasible to include in outpatient letters and how this may change with the implementation of more integrated electronic patient record systems. This will help to inform phasing of implementation in Trusts.
- Engaging with specialist societies and relevant Royal Colleges to ensure that the standard meets their needs, they are engaged and support implementation of electronic outpatient letters, based on the standards.
- Developing case-studies for hospital clinicians and GPs on the implementation of standardised electronic outpatient letters that will provide good practice and lessons learned related to engagement, communication, dissemination and professional leadership.
The project was conducted according to the editorial principles for the development of record standards, developed by the RCP and adopted by the PRSB.
This standard is in the process of endorsement. A full list of members will be published shortly.