Overview

Health and care records can include hundreds of digital and paper documents. To provide the best care we need a standardised way of naming them so they can to be easily found when needed, particularly in an emergency.

At the moment information about a person’s previous care may be held on a number of IT systems, brought together as a patient’s digital record. In their efforts to create a full set of digital notes, many trusts are also scanning historical paper records into digital files. As a result, these are often hard to navigate or difficult to retrieve from the system, increasing the risk of errors.

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 clinicians to compare and contrast previous test results, scans and other information, and patients won’t have to repeat complicated medical histories.

The PRSB is aware that while standardised document naming will be extremely useful, other information tags are also needed to locate specific documents, especially for people with complex care histories who have large document files. The next step will be to develop a standard for identifying documents using additional tags, known as metadata. This will ensure the relevant documents can be easily located within a person’s care records.

The standard was developed in partnership with the Royal College of Physicians (RCP) Health Informatics Unit (HIU).