15 April 2015

Guidance recommends how to make records clearer

User testing of Clinical Documentation and Generic Record Standards (CDGRS) recommends how to clarify important headings and clinical descriptions.

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 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.

The testing approach replicated the "real life" use of the headings in normal clinical practice as far as possible. It involved junior doctors watching 6 videos of doctors and actor patients in various patient admission scenarios. Participants were then asked to complete admission clerking forms based on the CDGRS headings, entering relevant information from the clinical interaction under the headings they thought were most appropriate.

The completed headings documents were then analysed by the project clinical lead to identify any issues with the headings. Clinical colleagues checked, confirmed and corroborated the assessments of the clinical lead. A debriefing meeting was then held with the participants to explore their experiences of the project, issues with the headings, areas of confusion and identification of any potential gaps or areas of duplication within the CDGRS headings.

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