Electronic health and care records can include hundreds of digital and scanned paper documents. We need a standardised way of naming them so they can easily be found when needed, particularly in an emergency, and exchanged efficiently between different systems.
At the moment, information about a person’s previous care may be held on a number of IT systems; a variety of options being available to provide a single view to a patient’s digital record. Such information may have been captured in a number of ways, for example:
- As a pdf which has been exported from an IT system
- A scanned document: In their efforts to create a full set of digital notes, many trusts are scanning historical paper records
- As a word-processed unstructured document
- As a pointer to a file in a document management system
As a result, without appropriate additional data (referred to as metadata), these are often hard to find or even know they exist, and can be difficult to retrieve, thus increasing the risk of error.
The document naming standard will ensure that records are properly named and indexed, so they can be retrieved in order to provide ongoing care. It will enable end users to compare and contrast previous test results, scans and other information, and patients won’t have to repeat complicated medical histories.
The current form of the document naming standard is:
- Guidance and recommendations for information tags (metadata) to hold alongside the document
- A standard for the metadata item: Document Type/subtype (referred to as the Clinical Document Indexing Standard)
- National data files can be obtained for the text for Clinical Specialty from Public Health Scotland, or the value set provided within the NHS Data Dictionary from NHS Digital (Care Professional Main Specialty Code)
The clinical document indexing standard was developed by the Scottish Health Boards in partnership with Public Health Scotland and has been used for a number of years. NHS Wales have also adopted the clinical document indexing standard utilising the SNOMED CT codes provided.
Recommendations for the next steps was developed in partnership with the Royal College of Physicians (RCP) Health Informatics Unit (HIU) and can be found in the PRSB Final Report.
Currently PRSB are working to develop a UK standard for the metadata tags and to provide a downloadable national value set for clinical specialty. Further guidance will also be provided in relation to data items which are frequently captured as structured data items in an EPR, such as allergies and alerts.
- Royal College of Occupational Therapy
- Royal College of General Practitioners*
- Royal College of Nursing
- Royal College of Midwives
- Royal College of Physicians
- Royal College of Paediatrics and Child Health
- Royal College of Emergency Medicine
- Royal Pharmaceutical Society
- Royal College of Psychiatrists
- Royal College of Obstetrics and Gynaecology
- Royal College of Radiologists
- Royal College of Pathologists
- British Psychological Society
* The RCGP support the standard and direction of travel in what is a very important area, recognising that further work to build on this standard and create a metadata standard is required to make it suitable and implementable for primary care and the system as a whole. a
IHRIM record correction guidance
Despite vigilance when filing information in records, mistakes can occur. The Institute of Health Records and Information Management has guidance to support professionals in making corrections following errors.