RCP launches generic record-keeping standards

12 Sep 2007

New standards for generic medical reporting have been developed by the Royal College of Physicians health informatics unit (HIU) and supported by NHS Connecting for Health.

The college says that the purpose of the standards is to maximise patient safety and quality of care, support professional best practice and assist compliance with information governance and NHS Litigation Authority standards.

There are 12 generic record keeping standards listed in total, that the college says are applicable to any patient’s medical record.

Professor Iain Carpenter, clinical lead for records standards at the RCP Health Informatics Unit, said: “Standards that can be applied to medical record keeping are an essential component of ensuring patient safety and best quality of care. These generic standards reflect the views of the medical profession and Department of Health.

“They represent the first steps in a programme supported by Connecting for Health, establishing professional standards for all components of medical records which are increasingly important with the advent of the NHS Electronic Patient Record.”

A spokesperson for the RCP added: “The quality of medical records is fundamental to the quality and safety of patient care, but at present there is no one agreed medical records standard in the NHS - each hospital has its own way of recording patient information.

“Mistakes and missing information in records are common and are a major contributory factor in medical errors and poor clinical care, leading to complaints and medical negligence cases.”

The process of developing these standards originated from a 2003 review for the RCP’s Clinical Medicine journal.

Information about the standards is being disseminated through the RCP to NHS trusts, and is being sent out as National Guidance through the Department of Health's Communications Directorate. The HIU is now developing an audit tool so that hospitals can measure how accurate and effective their records are.

Professor Martin Marshall, deputy chief medical officer for the Department of Health said: “Adherence to these common sense standards will deliver benefits to both patients and clinicians and will clearly demonstrate the link between improved information governance and improved care provision.”

Professor Michael Thick, chief clinical officer, NHS Connecting for Health added: “This will be a most important step towards standardisation, which in its turn will ensure unambiguous communication and safety. I also look forward to the next step, which will be a continued collaboration between CfH and the Royal Colleges to produce electronic messages to support this.”

The standards have also been approved by the British Medical Association and the Medical Defence Union.

Dr Vivienne Nathanson, director of professional activities at the BMA said: “Medical records are fundamental to good clinical practice. Decisions in relation to patient care have to be clearly recorded and structured if we wish to provide a consistent account of when, why and what was agreed between a patient and their medical practitioner. Clear records are also vital to the important issues of safety and confidentiality.”

Dr Catherine Wills, Medical Defence Union (MDU) medico-legal adviser, added: “Records are primarily intended to support patient care but we also receive a number of requests for assistance with cases where problems with the medical records make it difficult to respond effectively or provide a successful defence on behalf of our members.

“The cases we have provided illustrate the importance of ensuring there are detailed, accurate and contemporaneous records - primarily for the care of the patient but also because at some future time, the records may be important medico-legally.”

The RCP is now looking at standards for the structure of admission, handover and discharge records for incorporation into the electronic patient record.

Reader's Comments

Medical, clinical or health records?

12 Sep 07 09:40

This seems to be an example of just one minority element of the medical profession - the physicians - running ahead and defining record standards. Does this mean that other medical specialties (as well as other health professions) will need - possibly reluctantly - to follow the same general approach they have established?

If so, it's a pity that CfH has colluded in this fragmentary process rather than - through its professional engagement mechanisms - seeking to achieve an inter-disciplinary consensus record standard.

standards should be welcomed

ben.toth@gmail.com

12 Sep 07 13:24

I hope we don't get stuck in an inter-profession bunfight over these standards. Whatever their origin, they look about right - I suspect they would be widely supported by patients. It would be interesting to have an audit of medical records against these standards, and also to promote an information architecture which makes them possible.

So non controversial , yet listen to the controversy!

12 Sep 07 16:15

These standards are so obvious and non controversial that I am surprised by the flood of angry emails that I have seen in relation to them! Yet nearly every set of medical records that I see falls below these standards. In acute services now team working and continuity of care are long gone memories, so that being able to identify who saw and treated a patient is vital, yet most doctors still only add a squiggle at the end of their notes. It is essential that standards are driven up and the RCP is to be congratulated on producing the shortest most sensible piece of official dictat that I have seen in many a year!

Non-controversial?

colin@clinformation.com

13 Sep 07 08:17

I beg to differ!

(1) This seems to be a "silo" standard development, probably undertaken at some cost to the taxpayer, which does not obviously fit with the wider espoused approach of the NHS to shared records.

(2) History ought to have shown the NHS that taking a restricted professional pespective in the early stages of developing a standard for eventual inter-dsciplinary use can lead to later problems. For example, the findings of the GP2GP record transfer project after exploring the use of the record headings already developed by the "Headings for Communicating Records Project" ? The experience of GPs, nurses and allied health professionals joining the Clinical Terms Project after the hospital doctors had already done significant development work on Read version 3? It's both easy and expedient to develop standards in isolation; the real challenge is to build wide consensus from the start.

(3) There is also an issue of the role of the NHS ISB, on whose website I can find no evidence of this standard that is about to the promulgated to NHS trusts (though I may have looked in the wrong place and perhaps someone in-the-know will be able to put me right here). If ISB has not approved this then one has to wonder whether all the right processes are in place? Or - indeed - whether -the ISB now serves any useful purpose?

So, whilst I applaud the RCP's initiative in developing its own medical records standard, it raises for me (controversial) issues about strategic fit and VFM.

Missed opportunities

13 Sep 07 10:35

How sad that these standards seem to apply to written records only and that the opportunity was not taken to expand them to apply standards for electronic records. This is vital in these days of the electronic patient record. How sad CfH did not take this opportunity (or are they worried the products would fail?).

There should (one could argue MUST) be a multi-professional approach and this is another missed opportunity as the NMC (Nursing), RCS (surgeons), And the Allied Health Professional bodies have had record keeping standards for many years. What a shame CfH and the RCP did not include all these professionals.

What's the problem?

maryhawking@tigers.demon.co.uk

15 Sep 07 17:01

I knew hospital records were a mess, but if these sensible, straightforward guidelines are causing angst - well, the situation must be even worse than I had been led to believe! They appear to cover proper identification of the individual patient, including who is responsible for their care, availability, attribution of every entry, documentation of care and explanation of apparently missed periods of care. GPG v3.5 (Good Practice Guidelines) is far more prescriptive!

I note (with interest) the footnote saying that the NHS number is being introduced as a universal identifier. I thought that had, theoretically, happened in 1/4/1991!

The problem?

colin@clinformation.com

17 Sep 07 09:17

In response to Mary's question: if there was only a single clinical Royal College, and if the NHS hadn't been working for several years at some considerable effort and expense to develop shared electronic records (currently envisioned as SCRs and DCRs), then it would be hard to criticise this initiative as its objectives are clearly sound.

However, given the actual NHS context, the rationale for a limited perspective seems open to question: precisely why didn't CfH ensure that a wider consensus was achieved from the start? Perhaps only physicians keep important records? Or physicians' records are so poor that they need special attention? Or this was a "quick win" which NPfIT could latch onto?

NHS numbers

17 Sep 07 09:54

with regards to Mary's comment about NHS numbers being unique identifiers, this was perhaps the intent, but due to sloppy work in GP practices, midwifery units and local HAs many many people have duplicated numbers. Examples being family members with the same initials, twins registered without forenames etc This was painfully apparent during 5 years' work migrating patient data between primary care systems, and especially setting up new ones hased on an HA's electronic records few a GP's list These duplications were the root cause for a lot of spine patient traces and updates going horribly wrong, and a major reason for my refusal to be dragged into the data migrations of secondary care systems to LSP deployments of iPM (another being told to shut up when I pointed out Read Codes are case sensitive, and blood pressures are made up of two numbers in a specific order...)

Serious concern

17 Sep 07 13:32

The most basic administrative or clinical functionality is utterly dependent on trustworthy patient identification. A tiny residual level of duplicate and concatenated records are inevitable in any Master Patient Index albeit highly unwelcome.

However one repeatedly hears serious concerns raised about the poor quality of central NHS number data.

Some of us have long wondered how, when the National ID card project alone is projected to cost as much as NPfIT (and take as long), an accurate NHS National demographics database could be in place by P1R1 (July 2004) and maintained for a tiny fraction of the total cost.

How can CfH press ahead with GP summaries etc (all accessed by NHS Number) if there is widespread lack of confidence in the integrity of the patient register?

Sadly I do not expect our questions to be answered.

It would be nice if ...

18 Sep 07 00:55

... Physicians actually entered any data.

With a few notable exceptions, most Physicians I come across in my daily working life in the NHS rely on Medical Secretaries or more lowly clinicians to keep electronic records for them.

Of course I generalise and exclude GPs (who have their own Royal College) who are at least 10 years ahead of their hospital-based cousins.

ISB

jason.bradley@easynet.co.uk

19 Sep 07 13:41

Further to the reference to ISB in a previous post, there is an interesting document on the ISB website titled: Health Record and Communication Practice Standards for Team Based Care, 18/07/2005. It can be found at: http://www.isb.nhs.uk/about-isib/isb-publications/isb-publications#record

NHS Numbers

andy.hadley@ferndown.nhs.uk

19 Sep 07 14:58

Whilst GPs were linked into the FHSA databases, and this was linked to the Administrative Register, the work on providing hooks for secondary care systems into the same single source was stopped as an early ridiculous act of NPfIT.

It is still difficult for hospital staff to get the NHS number at the point of first contact unless it is an elective patient, and the GP includes it on the referral.

I think it was political cowardice that prevented the new format NHS Numbers being issued to citizens (at the same time as the centre were pretending that Identity Cards were not coming). Not only are we now getting very expensive ID cards, these will undoubtedly not link up with the NHS number, the EU Health Insurance Identity, or the many other identities.

One has to wonder whether government works for the big companies delivering these multiple deals rather than the citizens who pay for it all.

What is contraversial ?

andy.hadley@ferndown.nhs.uk

19 Sep 07 15:52

It is no suprise to me that physicians have invested time in developing these standards. A surgeon would tend to have a much shorter relationship with a patient, 'are they stable enough for my intervention', but especially for Elderly, Endocrinology, Cardiac or Renal patients, physicians may return to seeing the same patient and record many times.

Indeed for our EPR work from 1999, we started with Medicine for the Elderly, as the department with the most to gain from immediate access to at least parts of the record.

The saddest part is perhaps that it has taken 4 years to develop them, but if as reported, the BMA have adopted them, it is perhaps the Nursing and AHP bodies whom one might hope would follow.

And I also hope that the RCP in turning their gaze to electronic records do so in the context of the work that has been done on local EPRs, LSP, SCR and CUI plans.

Does it matter that one body creates the standard ? Presumably any tweaks or dissent will be evidence based...

Re: It would be nice if...

20 Sep 07 09:05

The comment about physicians not entering data is ill-informed if not tendentious. One wonders whether the writer actually understands the term 'physician'.

Re: What is controversial?

colin@clinformation.com

20 Sep 07 11:20

In the 1950s and 1960s, the RCP might well have handed down its standards to the NHS (after endorsement from the BMA) and confidently expected other professional groups in the "NHS happy family" to follow. However, the 21st Century NHS is a more pluralist environment in which there is often strong factionalisation between professions on various issues: in my experience these have included standards for records, clinical terms, user interfaces etc. The result is that developing widely-agreed standards can be both difficult and time-consuming.

From its inception, many of the objectives of NPfIT have been to do with inter-disciplinary information sharing and so it makes little sense in 2007 to create and disseminate information standards that have not been developed cross-professionally. The ISB with its diverse representation (not the BMA) is surely the body to agree these (and I say that as a BMA member of 30 years standing)? It would be interesting to understand the relationship between the ISB document highlighted by Jason Bradley in a previous comment, and this new work.

There is - though - perhaps a more fundamental issue here. If the NHS is still unable to engage widely in the development of a basic record standard, what chance of nurturing multi-disciplinary buy-in to CfH's offerings?

It would be nice if ...

nhstechie@btinternet.com

20 Sep 07 23:17

... the commentator on my earlier comment wasn't so patronising and humourless.

Sadly, my comment was based on years of experience both as a colleague and as a patient with a long term condition. For the record, one assumes physicians in this context to be hospital doctors from a wide range of specialties.

Perhaps my comment was a pawky reflection of stereotypical thinking, but if it wasn't based on at least a modicum of truth the 7th, 10th and 11th bullet points wouldn't be necessary!

I welcome these guidelines, if universally adopted perhaps GPs might be more likely to receive discharge letters a little more quickly than is currently the norm. It is ridiculous in this day and age that GPs have to rely rely on their patients' recollection of hospital visits because "the notes and discharge letter haven't been written up yet" - often over two weeks after the event. Maybe my patient experience is unusual, but GP friends tell me this is far from a rare occurence.