Which standards have changed?
How we developed the standards
PRSB standards are evidence-based and developed through a collaborative process that includes extensive consultation with the widest possible range of clinicians from the colleges and specialist societies, professionals who work in social care and informatics, system suppliers, patient representative groups and people who use health and social care services as well as carers. Consultations are undertaken via stakeholder workshops and online surveys and contributions number in the thousands for each standard produced.
The revised PRSB Standards for the Structure and Content of Health and Care Records build upon the original standards published in 2013 and further work has been undertaken to align the clinical record standards to technical standards (FHIR profiles) necessary to ensure information can be shared interoperably from one IT system to another. All the existing record standards are being brought together, with older versions being updated, to ensure that there is consistency across all the record standards.
The work was undertaken in partnership with NHS Digital, INTEROPen and the Royal College of Physicians Health Informatics Unit.
Creating the revised standards:
The process involved:
1. Mapping all the subsequent developments back to the last version of the consolidated standards (published by the Academy of Medical Royal Colleges and NHS Digital in July 2013). This was done to identify changes since 2013 and any differences between the subsequent developments
2. Applying changes in the following circumstances only:
- Changes in legislation (or where heading descriptions previously referenced legislation solely in England)
a. Advance decision to refuse treatment (ADRT)
b. Cardio-pulmonary resuscitation (CPR) decision
c. Mental capacity assessment
d. Mental Health Act or equivalent status
e. Lasting power of attorney for personal welfare or court-appointed deputy (or equivalent)
- Addressing issues or clarifications requested since publication
a. Where more detailed content had been specified under the original heading.
b. Where there were changes required to align with FHIR profiles.
3. Developing a consolidated set of implementation guidance and consolidating the clinical standards report for similar use cases (transfers of care).
All standards which are covered by this maintenance release have already been developed in projects conducted according to the PRSB process and assurance criteria and have already been endorsed by appropriate professional bodies.