Developing a conformance methodology for clinically-defined medical record headings:a preliminary report.

Background: The Professional Records Standards Body for health and social care (PRSB) was formed in 2013 to develop and assure professional standards for the content and structure of patient records across all care disciplines in the UK. Although the PRSB work is aimed at Electronic Health Record (EHR) adoption and interoperability to support continuity of care, the current technical guidance is limited and ambiguous. Objectives: This project was initiated as a proof-ofconcept to demonstrate whether, and if so, how, conformance methods can be developed based on the professional standards. Methods: An expert group was convened, comprising clinical and technical representatives. A constrained data set was defined for an outpatient letter, using the subset of outpatient headings that are also present in the ep-SOS patient summary. A mind map was produced for the main sections and sub-sections. An openEHR archetype model was produced as the basis for creating HL7 and IHE implementation artefacts. Results: Several issues about data definition and representation were identified when attempting to map the outpatient headings to the epSOS patient summary, partly due to the difference between process and static viewpoints. Mind maps have been a simple and helpful way to visualize the logical information model and expose and resolve disagreements about which headings are purely for human navigation and which, if any, have intrinsic meaning. Conclusions: Conformance testing is feasible but nontrivial. In contrast to traditional standards-development timescales, PRSB needs an agile standards development process with EHR vendor and integrator collaboration to ensure implementability and widespread adoption. This will require significant clinical and technical resources

Medical records and record-keeping standards

The structure of medical records becomes ever more critical with the advent of electronic medical records. The Health Informatics Unit (HIU) of the Royal College of Physicians has two work streams in this area. The Record Standards Programme is developing generic standards for all entries into medical notes and standards for the content of admission, handover and discharge records. The Information Laboratory (iLab) focuses on Hospital Episode Statistics and their use for monitoring clinician performance. Clinician endorsement of the work is achieved through extensive consultations. The Generic Medical Record Keeping Standards are published in this issue of Clinical Medicine

Standardising medical records: improving patient care and informing the evidence base

Poor organisation and partial or inaccurate completion of clinical notes can cause problems ranging from frustration to litigation. Despite this, no country has processes in place to regulate record-keeping across medical facilities. In our Guest Editorial, Iain Carpenter, Mala Bridgelal Ram, and John G. Williams contemplate how new initiatives in the UK to standardise recording of clinical details could not only improve patient health care but also perhaps fill the gaps in the evidence not answered by RCTs

Why it is essential to go on the records

Medical records are at the heart of good patient care and an essential component of understanding what went wrong and if things do go awry