Improving how person characteristics are recorded in health records.

Accurate and comprehensive health records – including person characteristics such as age and gender – are essential for delivering high-quality care.

While some information about person characteristics is currently collected in NHS systems, much of it is gathered for secondary purposes such as population analysis. This lack of detail limits its usefulness in clinical care. For instance, ethnicity data may be too broad to inform diagnoses or evaluate how treatments work for individual patients. Similarly, transgender individuals may face challenges with screening programmes that require manual workarounds to ensure they are invited for appropriate health checks based on sex-specific risks.

About the project

PRSB are leading a consultation for NHS England to explore how person characteristics are used in clinical decision making and improve how they are recorded in care records. The person characteristics being considered as part of this discovery project include: 

  • Age 
  • Disability and impairment 
  • Gender identity  
  • Gender reassignment 
  • Marriage and civil partnership 
  • Pregnancy and maternity 
  • Race and ethnicity 
  • Religion or belief 
  • Sex 
  • Sexual orientation


Gender identity has been included alongside 9 other person characteristics (which are protected characteristics under the Equality and Gender Recognition Acts) so that we can explore issues arising when the terms sex and gender are used interchangeably in patient records.

Working in partnership with the Federation for Informatics Professionals and closely with a diverse stakeholder community, we aim to inform a standardised approach to making healthcare more inclusive, efficient, and person-centred.

Woman receiving care in the community smiling into camera

Aims and objectives

This project aims to gather intelligence on the clinical requirements relating to person characteristics to help identify data items relating to these characteristics which are routinely needed when treating patients, but which aren’t generally available within IT systems in use in the NHS. By capturing the right information about person characteristics:

  • Clinicians will have the right information to inform clinical decision-making and reduce risk of clinical harm.
  • People will be addressed in the way that they choose and have an improved experience and will not need to keep repeating information about how they want to be addressed or their gender history. People will receive the appropriate care and preventative care (e.g. screening) based on the correct recording.

 

Our consultation will highlight challenges and opportunities in:

  • Ensuring key characteristics such as sex, gender identity, and ethnicity are accurately recorded without compromising safety or dignity.
  • Creating a more inclusive, person-centred approach that reflects the complexity of individual health needs.

 

How to get involved

We’re keen to hear from clinicians and people with lived experience relating to the recording of their person characteristics who would like to be involved in the consultation. For more information, please contact info@theprsb.org