New care record guide to support patient safety and better care

Sharing data with pharmaciesThe Professional Record Standards Body (PRSB) has published its revised standards for the structure and content of health and care records to support digital information sharing among professionals and help people access better, safer care.

The “PRSB Standards for the Structure and Content of Health and Care Records” are an essential resource that describes the standardised information that should be gathered and shared in care records, which can then be exchanged digitally across the NHS and social care, whenever and wherever they are needed. The publication contains the structure and descriptions for the content of health and care records.

PRSB has revised and aligned its standards to support the digital exchange of health and care records and communications between different systems, using Fast Healthcare Interoperability Resources (FHIR). When combined, standardised care records and FHIR technology will allow information to flow directly from one IT system to another helping people to access safe, high quality, timely and efficient care. The work forms part of the drive within health and social care to improve the use of information and technology. This will give patients more control over their health and well-being, empower carers by ensuring they have access to information, reduce administrative burden for care professionals and support research and the development of new medicines and treatments. INTEROPen has published the first FHIR profiles, which will support the transfer of information between different systems.

Publication of the 2018 “PRSB Standards for the Structure and Content of Health and Care Records” replaces the 2013 “Standards for the Clinical Structure and Content of Patient Records”. The PRSB standards have been updated to reflect current professional practice and incorporate new or changed structured content resulting from the development of detailed transfer of care standards. They have been developed with input from thousands of professionals from all health and social care specialties, carers and people who access services. They agreed what information is essential to share in order to provide timely, high-quality care efficiently that is well-coordinated and meets an individual’s needs.

This is the first major release since 2013 and PRSB has produced guidance, FAQs and other materials to help organisations and system suppliers replace previous versions of the standards in their information systems.

Professor Maureen Baker CBE, chair of the PRSB, said: “We now have the key ingredients that health and care services need to join up information anywhere, at any time in the system. With the publication of the PRSB revised standards aligned to FHIR technology we are now poised to deliver truly shared care records and reap the benefits of safer, better, more efficient care.” The standard has been published by the PRSB in collaboration with NHS Digital and the Royal College of Physicians Health Informatics Unit.

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