Structure and content of health and care records
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Structure and content of health and care records
PRSB has revised and aligned its standards to support the digital exchange of health and care records and communications using Fast Healthcare Interoperability Resources (FHIR). When combined, standardised care records and FHIR technology allows information to flow directly from one IT system to another, helping people to access safe, high quality, timely and efficient care.
The PRSB structure and content of health and care records is the essential resource that describes the standardised information that should be gathered and shared in care records so that they can be exchanged digitally across the NHS and social care, whenever and wherever it is needed.
The document replaced the 2013 Standards for the Clinical Structure and Content of Patient Records and has been published to reflect current professional practice and incorporates new or changed record structures and content resulting from the development of detailed transfer of care standards and integrated care standards.
The following PRSB standards have been updated in this release. Detailed release notes are available for each standard outlining the changes made. Please use the links below.
The standards have been developed with input from thousands of professionals from all health and social care specialties, carers and people who access services. They agreed what information is essential to share in order to provide timely, high quality care efficiently that is well-coordinated and meets an individual’s needs.
For more information or help with queries contact the PRSB at info@theprsb.org.
CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:
1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.
2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests.
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.
3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history.
• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.
4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning.
This links to the fifth principle that:
5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”