Record Standards Project Tom Lawton Jan 2017

Health Informatics Unit, RCP Royal College of Physicians Other colleges via links with AoMRC Professors John Williams, Iain Carpenter Summer 2006 – Accidental job application November 2006 – Start of Record Keeping Standards project

Record Keeping Standards, 2006 Develop standards for recording and communicating information about patients Apply these standards to operational records to improve the validity and utility of patient data Structure the records so that the information can be incorporated into electronic records, shared with other healthcare providers and analysed with confidence Care Records Service/Connecting for Health

Topic areas General record standards Admission Handover Discharge Outpatient letters

Project results, 2008

E-Learning, 2009 Formerly on CfH Information Governance Training site Now: Embedding Informatics in Clinical Education “The importance of good clinical record keeping” “Record keeping standards for hospital inpatients”

CDGRS, 2010 (Stage 2) Generic Editorial Principles for development and maintenance of record keeping standards. Prioritised Core Clinical Headings with Definitions of headings that will be priority for development and implementation into the Electronic Health Record Scoping for the development of standards for Outpatient Letters and Referral Letters Review and confirmation of the detailed data items under the already established headings for the Hospital admission, Hospital handover and Discharge summary Patient Journey Development for Hospital admission, Hospital handover, Discharge summary, Outpatient letter and Referral letter

Project results, 2013 Clinical Headings Core – priority for coding (SNOMED-CT) Admission Handover Discharge Outpatient Referral

Example of standards

Present & Future