Using the standard
In order to be able to ‘find’ these documents easily, whether paper documents scanned into digital documents or newly created documents from dictation or outputs from health or social care systems, they MUST have a name and they MUST be identifiable. The PRSB document naming standard specifies the way that the name of a document should be structured so that people or care professionals accessing care records can find it easily, anywhere. It can be a single item that is coded using SNOMED CT, thus making it searchable. There is a pre-existing list that should be used to select the document name, published by NHS Scotland and available online.
The ‘document name’ is only one piece of information recorded about a document and only one way of searching for and identifying it. It should be viewed as part of a much wider set of details used to describe a document. Other information needs to be held about a document to enable it to be easily located. For example a discharge letter from an orthopaedic service should be ‘named’ as a discharge letter (part of the ‘correspondence’ content) and the specialty is orthopaedics. Additional tags will be added e.g. author and date, hospital/clinic
and speciality services and so on.
When every document is appropriately tagged this will allow professionals and people accessing care to assemble the digital record into a navigable structure.
- I want to look at letter that X dictated.
- I want to look at letters done in orthopaedics.
- I want to look at all letters.
- I want to look at discharge letters.
- I want to look at all orthopaedic discharge letters.
- I want to look at all orthopaedic discharge letters that X dictated.
The PRSB document naming standards builds upon existing naming standards. The PRSB believes that document naming should be mandatory and use published lists including the NHS Scotland document indexing standard and the NHS Data Dictionary as well as SNOMED CT to ensure documents are searchable.
Naming conventions should be clear and unambiguous so that any user – whether a patient, clinician or administrator – can easily retrieve documents. The document naming standard should apply to scanned paper notes as well so that these documents are as accessible as fully digital records.