Health and care records can include hundreds of digital and paper documents. 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). Endorsement was sought for the final report and recommendations.
- 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.
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.