People can easily have hundreds of digital and paper documents in their health and care records and a standardised way of naming them is essential if they are to be easily found when needed, particularly in an emergency.
A new document naming standard developed by the PRSB in partnership with the Royal College of Physicians (RCP) Health Informatics Unit (HIU) will ensure that records are properly named and indexed, so they can be retrieved in order to provide ongoing care. At the moment information about a person’s previous care may be held on a number of IT systems, brought together as a patient’s digital record. In their efforts to create a full set of digital notes, many trusts are also scanning historical paper records into digital files.
As a result, these are often hard to navigate and difficult to retrieve from the system, increasing the risk of treatment errors.
“This new standard will generate consistency throughout the NHS, by ensuring documents are correctly named and can be easily located in online systems,” said Dr Neelam Dugar, consultant radiologist at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust. “For example, if a clinician needs access to a patient’s previous x-ray results, these can all be found under ‘radiology reports’, rather than a range of different places. Ultimately this will make care better and safer for patients, by ensuring easy access to important information,” added Dr Dugar, who led the project for the PRSB.
In addition to enabling clinicians to compare and contrast previous test results, scans and other information, patients won’t have to repeat complicated medical histories and it will reduce the risk of vital data getting lost.
The PRSB is aware that while standardised document naming will be extremely useful, other information tags are also needed to locate specific documents, especially for people with complex care histories who have large document files. The next step will be to develop a standard for identifying documents using additional tags, known as metadata. This will ensure the relevant documents can be easily located within a person’s care records. For example, a GP could find a specific test result using the date and who it was recorded by, in order to make well-informed decisions about a person’s ongoing care.