New standard for clinical referrals will support faster, better patient care
Referrals to hospital are increasing as more people continue to live longer with a range of complex conditions. The PRSB recognise that good information sharing is integral to ensuring that patients can receive the ongoing care that they need. Currently there are differences between GP systems and GP practices in the clinical content of referrals, with multiple templates in use.
The clinical referral information standard is designed to improve the exchange of referral information from GPs to hospital consultants and other health care professionals providing outpatient services.
Working with clinicians and patients, we have published this standard along with implementation guidance for digital referrals from GPs to hospitals. Once implemented, it will ensure that clinicians have the right information they need to provide the best care for patients. The standard was produced in collaboration with the Royal College of Physicians Health Informatics Unit and input from the Royal College of General Practitioners.
By using the standard professionals will have access to all relevant information in a timely manner results in safer and more consistent care for people using health and care services. The information will include data about medication, previous history, allergies and current symptoms, as well as a patient’s concerns and expectations.
Version 1.1 - Standard update
This standard has now been updated to version 1.1. Detailed release notes are available outlining the changes. These can be found in the supporting documents link above. The standard has been updated in-line with new PRSB digital medications information assurance.
The PRSB has worked in partnership with the Health Informatics Unit at RCP to produce these standards.
Below you can find a series of supporting documents for the Clinical referral information standard.
Release Notes V1.1
The Clinical referral information standard has been updated to version 1.1 (Dec 17 2019). V2.1 includes an update to:
- structured dose direction cluster
- structured dose amount
- structured dose timing and dose direction duration.
Clinical referral information standard - record specification
Download the record specification (displayed in the contents section) as an Excel file.
This guidance sets out issues identified during the project which relate to the implementation of the headings and sub-headings.
The final report outlines the process taken to reach the final standard.
The findings and analysis from the Clinical referral standard survey consultation process.
Clinical referral safety case report
This document is a report of the work done to manage identified clinical safety risks associated with the clinical referral information standard project.
Clinical referrals hazards log
The hazard log records both generic and specific implementation hazards identified during project phase.
The Clinical referral information standard has been endorsed by the following organisations:
- Royal College of Occupational Therapists
- Royal College of General Practitioners
- Royal College of Nursing
- Royal College of Physicians
- Royal College of Obstetricians and Gynaecologists
- Royal Pharmaceutical Society
- Royal College of Paediatrics and Child Health (RCPCH)
- Institute of Health Records and Information Management