1. Record Standards Project
Tom Lawton Jan 2017

2. 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

3. 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

4. Topic areas General record standards Admission Handover Discharge
Outpatient letters

5. Project results, 2008

6. 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”

7. 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

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

9. Example of standards

10. Present & Future