Which standards have changed?
Frequently Asked Questions
Why is the PRSB changing the standards for the structure and content of health and care records?
The standards for the clinical structure and content of patient records were published in 2013, to define the structure and descriptions for the content of digital health and care records based on certain patient pathways. Since they were published we have gone on to develop more detailed standards to support health and care providers to record and share information. This publication replaces the 2013 standards and brings them into line with both the more detailed standards, which required some new record structures and modifications, to be used with technical standards for implementing FHIR (Fast Healthcare Interoperability Resources) profiles. FHIR is a technical standard that enables systems to exchange healthcare information electronically.
What are the changes PRSB has made to the standards?
The changes are mainly updates to the names of the structured content, descriptions, and value sets. In some cases, the names of the structured content have been combined or new ones added. To support clinicians, professionals and IT staff, we have prepared release notes and updated our implementation guidance. Please refer to the individual standards on our website at www.theprsb.org/standards .
What standards have changed?
The PRSB uses the structure and content of health and care records as a foundation when developing new record standards. The standards updated in this release:
- eDischarge summary
- Mental health inpatient discharge
- Emergency care discharge
- Outpatient letters
- Crisis care summary
The updated structures include the following:
- All record structured content
- Admission clerking
- Hospital discharge summary
- Mental health discharge summary
- Emergency care discharge summary
- Outpatient letter
- Crisis care summary
New standards which are up to date:
- Digital care and support plan
- Healthy child record
- Maternity records (due imminently)
- Clinical referral information (due imminently)
Our IT system developer used the 2013 standards for the clinical structure and content of patient records to create templates for our hospital system, do we need to change our templates?
Providers will need to update their templates as part of implementing the standards at the detailed structured and coded level, as preparation for FHIR implementation. The NHS Standard Contract requires that providers implement the PRSB discharge standards. Providers who have implemented the 2013 headings will need to update their hospital system templates to meet this requirement. The standards and implementation guidance at www.theprsb.org/standards will guide you through this exercise.
Our IT system developer used the most recent standards published on PRSB’s website to create templates, do we need to change our templates again?
If providers have implemented the most recent standards, only minor changes to value sets will be needed to update their templates. Providers are recommended to update their hospital system templates as part of FHIR implementation.
How do I know if our templates are based on the old structured record content or the most recent standards?
Clinicians should contact their Chief Clinical Information Officer or IT department to find out if their templates use the most recent standards. IT staff and system suppliers should check their templates correspond to our most recent standards at www.theprsb.org/standards.
What should providers be doing to ensure their hospital system is ready for FHIR?
NHS Digital will publish guidance to provider organisations and system suppliers, supporting them to plan FHIR implementation. Updating hospital systems to align with FHIR profiles will be included in these plans.
I am a patient with online access to my heath and care records; will these updates change the information I can view?
No, if you access your health and care records online, e.g. through a patient portal or a GP online service, these updates should not affect your access to your information. If you want to know more about accessing your health and care records online, please contact your GP practice.
Where can I go for more information and support?
Please visit our website at www.theprsb.org/standards for information or contact us by email at email@example.com or ring 020 7922 7976.