London Collage ‘s National Standars for the Structure and content of Medical record

National Standards for the structure and content of medical records.

The Medical Record Keeping Standards Programme of the Health Informatics Unit at the Royal College of Physicians, London.

Prof. Iain Carpenter, Health Informatics Unit, Royal College of Physicians, London/Centre for Health Service Studies, University of Kent, Canterbury

Mala Bridgelal Ram, Health Informatics Unit, Royal College of Physicians, London

Professor John Williams, Director, Health Informatics Unit, Royal College of Physicians, London/ School of Medicine, Swansea University

Patient medical records serve two principal purposes. The first is to support direct patient care by acting as an aide memoir for clinicians and supporting clinical decision making. The second is to provide a reliable source of data to support clinical audit, research, resource allocation and performance planning.  In the UK, the link between the two is the coding of diagnoses and procedures during a hospital stay that is then returned centrally for analysis and publication in the Hospital Episode Statistics.  We describe how the Health Informatics Unit at the Royal College of Physicians in London has co-ordinated the development of nationally agreed standards for the structure and content of medical records that have been agreed for all hospital specialties.

The programme emerged from a project aiming to compare the performance of gastro-enterology services between hospitals by analysing Hospital Episode Statistics (HES).  The study concluded that it was impossible, possibly because of errors in the coding of diagnoses and procedures imprecisely recorded in medical notes.  An audit of 149 sets of medical notes from 5 hospitals found that there was such variability between hospitals in how records are structured and organised that a comparative audit was not possible.   A subsequent literature search for evidence of the benefits of standardised medical notes, though patchy in coverage, demonstrated benefits to patient safety and care outcomes, as well as likely improvement in ease and accuracy of clinical coding.  This initiated the Record Standards programme at the Health Informatics Unit (HIU).  The national programme to develop an Electronic Patient Record (EPR) for the National Health Service (NHS) in England gave added weight and urgency to the work, as an EPR requires standardisation of data, ideally reflecting best clinical practice rather than requirements of a computer system.

The goal was to develop consensus and evidence based structure and content standards for medical notes that would reflect professional best practice and be acceptable to all medical and surgical hospital services.

Our first step was to draft content and process standards for medical records from both the literature review and a review of standards published by medical professional bodies.  The standards covered generic issues applicable to all medical notes as well as headings to standardise the structure of admission, handover and discharge records.  The HIU separated the generic and content standards and consulted widely, seeking the views of practising doctors and professional and policy bodies.  Generic Medical Record Keeping standards were published by the College in 2007[1].

The development of the admission, handover and discharge record keeping standards started with a poll of practising hospital doctors to gauge the enthusiasm for standardising notes structure.  The question asked was ‘Should the same, standardised headings be used in the proforma for acute medical admissions in all NHS hospitals?’.  In the first of these, conducted by Doctors.net, 2:1 responded in favour, a second poll, of Members and Fellows of the RCP found 4:1 in favour.  Both polls were closed at 1,000 responses (Carpenter et al, 2007). 

With evident support for the proposal confirmed, examples of admission clerking documents from 36 NHS hospitals were used to produce draft headings which were then revised in a series of workshops and then put out to consultation in on-line questionnaire.  The workshops and on-line questionnaires included patients and carers from the RCP Patient Carer Network.  Over 3,000 doctors responded to the questionnaire and contributed over 1,500 written comments.  Of those who responded to the questionnaire, over 90% were in favour of a common structure for the whole NHS.

A further series of workshops and an updated literature review developed headings for use in documents to support handover between medical teams and in discharge documents for when patients leave hospital, the latter with specific input from General Practitioners in primary care.  The on-line handover and discharge consultations each generated around 1,500 completed questionnaires.

At the same time, the Presidents of the all the UK Medical Royal Colleges and specialist societies were contacted and asked to identify nominees who would examine, with their colleagues, the headings for the different types of records from the perspective of their own specialty.  Their responses were fed into revised headings which were then used to structure paper proformas to test the headings in practice.  The product of the exercise was piloted in hospitals [admission (10), handover(11) and discharge(8)], the discharge summary pilot included GPs who received discharge summaries using the standardised headings.

On April 17th 2008, the final revised standards were ‘signed off’ by the Academy of Medical Royal Colleges, attended by the Presidents from all colleges, including surgical, mental health and child health.  They were passed as fit for purpose with observations from psychiatry and paediatrics that although the information that they required was different from and additional to that covered by the standardised headings, their requirements could be accommodated within the proposed structure standards.

The standards have now been submitted to NHS Connecting for Health which is responsible for the development of the EPR in England.  Work on definitions that will meet the rigorous requirements for IT implementation is underway. Once completed they will be submitted to the NHS Information Standards Board for Health and Social Care following which all IT system suppliers will be required to use them for their EPR solutions.  Many hospitals and IT suppliers are already implementing them in both paper and electronic format.

The project has been enthusiastically received by a very wide range of organisations including the IT industry which see them as the means for rationalising their clinical information system applications.  The NHS Litigation Authority, which provides the clinical incident indemnity for NHS providers, are incorporating them into their Risk Management Standards for providers and the NHS Care Quality Commission who register all NHS providers will reference them in their standards required for registration.  They are being incorporated into the medical undergraduate and post graduate training curricula and will likely be referenced in the General Medical Council ‘Tomorrow’s Doctors’ standards document that describes the standards for knowledge, skills, attitudes and behaviours that medical students should learn at UK medical schools. The standards are recommended for use in IT systems in Scotland and are being introduced in Wales.

The NHS Digital and Health Information Policy Directorate has published a two part clinician’s guide to the standards. 

Part 1 describes the rationale for the process of developing and introducing the national professional record keeping standards.  It also lists the expected benefits from their introduction.

Part 2 contains the Generic Medical Record Keeping Standards and the structure and content standards for admission, handover and discharge documents.  

The Guide can be downloaded as pdf’s or free hardcopies ordered on line at : www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/clinicians-guides.aspx


[1] Carpenter, Iain; Bridgelal Ram, Mala; Croft, Giles P; Williams, John G, 2007. Medical records and record-keeping standards. Clinical Medicine: 7(4):328-331

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