What is a care record standard?

PRSB standards are made up of information headings such as diagnoses, medications and allergies and a description of the information that should be recorded under each heading. These standards are intended for use by all health and care organisations and they support better sharing of information between organisations and individuals.

Why do we need care record standards?

Care record standards exist to improve the safety and quality of health and social care, in particular to ensure that the right information is recorded correctly, in the right place, and can be accessed easily, by any authorised person who needs it, wherever they are.

Developing and using electronic cared records built on the same standards means that the information recorded while providing or receiving health or social care can be shared between whomever, whenever and wherever appropriate. The record standards ensure the information made available is exactly how it was recorded.

How do care records benefit patients and professionals?

People who use services will only have to share information once, and their records will be available in every care setting including at home. In addition to helping professionals to provide safe and effective care, it also means that people have access to their own records and can take greater control of their care.

The information collected from people can also be used to make care better for the future through audit of existing treatments and services, improving the quality of care and research so we know more about illnesses and develop new and better treatments and care options.

Our role

The NHS is working to enable all IT systems across the health and care sector to talk to each other, called interoperability, which will ensure that the right information is available when it is needed to support safe, reliable care.

This is a huge task given the scale of services, procedures, specialties, diseases, treatments and drugs provided, plus the range of different clinicians and professionals involved in delivering care, means health and social care are much more complex than other industries.

As part of this work, and to enable information to be shared in a meaningful and consistent way, the PRSB is bringing together health and care professionals, and patients to develop standards for care records. This means that everyone agrees what information should be recorded at any stage of a patient’s treatment and care to ensure high quality care can be provided. It also means that IT systems can be designed to share and retrieve the relevant information when it is needed.

They are not the whole solution, but a key stage in a process that is just beginning, a process that with the right clinical leadership will ensure that technology is designed to support the NHS in delivering excellent patient care for the future.

What are the benefits of having record standards?

To patients, public and carers
You only need to provide details once. You can have access to meaningful personal health information.

To clinical practice
Professionals can agree best practice and capture it in an auditable way. They will have full access to the information
they need to provide good care

To integrated care and efficiency
Information can be captured once at source and shared efficiently with all professionals who need access

To safety
Record standards reduced risk  - medication errors
Full and timely access to complete information

To commissioners
Standards support joined up pathways and integrated, patient centered care

To personalised care
Care can be built around the individual and we can move away from fragmented disparate systems