Shared decision-making is at the heart of good care. In order to make good decisions about care and treatment, health and care professionals need time to discuss people’s needs and wishes, and people using services need information about their options and the time and support to decide what care decision is best for them. 

PRSB has published a standard that will capture the information from shared decision-making conversations in a consistent way, and allow this information to flow between the care providers that need it to deliver safe, high-quality care.

PRSB were commissioned by NHS England to create the standard in order to:

• Define what should be recorded in a person’s record about a shared decision
• Support ongoing discussions and provides an audit trail for discussions
• Support good professional practice as outlined in the GMC and NICE guidance on shared decision-making
• Support the sharing of decision-making information with other professionals

The standard was developed in UK-wide consultation with professionals, people who use services, system suppliers and informaticians to ensure it can be used in care settings. It involved rigorous research on what a standard for shared decision-making should include, followed by a wide-ranging consultation and eight scenarios that tested the standard with help from professionals and actors or people with lived experience of using services. The standard was produced and describes the information that is essential to document and share in order to provide well-coordinated care.

Shared decision-making plays an important part in the drive towards person-centred care and the standard will help to improve people’s trust in their care, giving them more control over decisions and an improved knowledge and understanding of their treatment, its risks, benefits and possible side effects. For health and care professionals, the standard will help to improve the legal and ethical process around reaching decisions about care.

“There is a growing body of evidence that shows many people increasingly expect and hope to be at the centre of all the health and care decisions that affect them. To have a standard for recording shared decision making conversations, would greatly improve the choice and decisions of millions of people, lead to better outcomes and, at the same time, support a genuine ‘patient-centred’ approach to healthcare,” said Lawrence Mudford, who co-led the PRSB project, based on his personal experience of care.

PRSB Chair, Professor Maureen Baker, added: “A consistent and standardised approach to documenting and sharing decision making information will give clinicians the information they need to communicate well with people, taking account of their individual wishes and set of circumstances. With this, a stronger partnership is created and all parties benefit.”

Notes to Editor:

The Professional Record Standards Body

• The Professional Record Standards Body (PRSB) is a body responsible for the development of standards for clinical record sharing across health and care.
• In addition to supporting safer and better care, use of the digital information standard will provide valuable information for secondary uses, which can support future research and developments in health and social care.