The way medical diagnoses and problem lists are recorded and the culture for recording information in primary and secondary care are different. The PRSB, in collaboration with the Royal College of Physicians, has completed guidance for the recording of medical diagnoses and problem lists in a structured form in patient records that enables standardisation and uniformity across primary and secondary care.
The guidance defines exactly what is meant by a problem, symptom and diagnosis. It also clarifies how all information should be recorded. There is a need for a wider programme of work on diagnosis recording beyond this project, e.g. defining the attributes of diagnosis and the educational support required to implement guidance on recording diagnosis. This report identifies the further work needed.
The PRSB worked in partnership with the Royal College of Physicians to produce this report.
We are publishing the guidance for trial use. We recommend people start with a few use cases, individual disciplines and even individual aspects of the guidance such as recording short-lived versus chronic conditions and new versus past conditions and check that it is workable and doesn’t impact the usual work flow. We are interested in hearing about your testing, how we could help you and how it goes. Please contact us via firstname.lastname@example.org with any questions and we welcome feedback on the guidance.