Core clinical headings for electronic health records

Transcription

1 Core clinical headings for electronic health records December 2012 Prepared by the Royal College of Physicians on behalf of the Department of Health Informatics Directorate in England Royal College of Physicians and Crown Copyright

2 The Royal College of Physicians The Royal College of Physicians is a registered charity that aims to ensure high-quality care for patients by promoting the highest standards of medical practice. It provides and sets standards in clinical practice and education and training, conducts assessments and examinations, quality assures external audit programmes, supports doctors in their practice of medicine, and advises the government, public and the profession on healthcare issues. The Department of Health Informatics Directorate in England The Clinical Data Standards Assurance (CDSA) programme is part of the Department of Health, Informatics Directorate in England. The CDSA programme brings together the clinical and professional communities in health and social care, patient representatives and technology resources to ensure that electronic health records reflect professional practice, and support improved patient outcomes and safety. The CDSA team are experienced professionals with clinical, technical and management skills, and unique experience in facilitating development, assurance, implementation and maintenance of Clinical Data Standards. Citation for this report: Royal College of Physicians. Core clinical headings for electronic health records. London: RCP, Copyright This document has been prepared by the Royal College of Physicians on behalf of the Department of Health Informatics Directorate in England. Layout and design Royal College of Physicians 2012 Information and content Crown copyright 2012 You may use and re-use the information featured in this document (not including logos or images) free of charge in any format or medium, under the terms of the Open Government Licence. Any enquiries regarding the use and re-use of this information resource should be sent to nhs.cfh.communications@nhs.net. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. Royal College of Physicians 11 St Andrews Place, London NW1 4LE Registered Charity No Royal College of Physicians and Crown Copyright

3 Contents Core clinical headings for electronic health records 3 The development of the core clinical headings 3 The underlying principles for core clinical headings 3 The core clinical headings 4 s within the core clinical headings 5 Appendix 1 The development of the core clinical headings 9 Appendix 2 Organisations Contributing to Core Clinical Headings 10 Royal College of Physicians and Crown Copyright

4 Core clinical headings for electronic health records The core clinical headings for electronic records are the product of a standards development programme led by the Health Informatics Unit (HIU) of the Royal College of Physicians (RCP) and funded by the Department of Health. The HIU led programme began developing national evidence and consensus based standards for clinical records in The development process includes review of published evidence and extensive consultations to gain consensus. The first product of the programme, standards for admission handover discharge records, were approved as being fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges in April 2008 and published as clinician s guides to record standards ( The development programme has continued, addressing outpatients, referrals and editorial principles for developing record standards. The development of the core clinical headings The core clinical headings were developed starting with a review of evidence followed by extensive consultations in workshops and on-line survey. The concept of a set of core headings that should appear in all clinical records proved difficult to define, and led to considerable confusion. The essence is that they are the minimum that should be embedded in all electronic health record (EHR) systems and that they are not exclusive. Different clinical contexts require additional headings, for example clinical examination findings are a fundamental part of clinical practice, but are not necessary for all clinical transactions presenting issues and diagnoses will suffice. Consultations resulted in a set of principles which underpin the core clinical headings. The headings and the underpinning principles were sent to all the medical royal colleges, specialist societies and professional bodies of the other clinical disciplines for final sign-off. This resulted in a further few minor amendments to some headings. The core clinical headings and principles were signed off by the Academy of Medical Royal Colleges as fit for purpose for the medical profession on 1 November The organisations whose representatives and membership contributed to the development extended across all the clinical disciplines, these organisations are listed in Appendix 2. The underlying principles for core clinical headings 1. Information recorded under a heading should never be separated from that heading when communicating the information. 2. The use of the core headings should give a clear summary of the patient s clinical state in the context in which the patient is seen. 3. The core clinical headings are the highest priority for early introduction into electronic health and care records. 4. All electronic health and care record systems should support them. 5. Core headings will not always be populated: this will depend upon context and data/ information availability. 6. The headings are intended to standardise the core content of records while maintaining essential simplicity. 7. The information recorded may be extended when appropriate, but if so, should be accommodated as new subheadings either within the core headings or other specific sets of national standard headings (eg admission, discharge, outpatients). Royal College of Physicians and Crown Copyright

5 8. The core headings apply to the patient-focused record and should be accessible in any care context as they form the basis of the clinical record in relation to any episode or contact of care. They are integral to providing high quality healthcare with the patient at the centre of the care. 9. Some items are static; some are changeable: the mechanism for recording change is through the record, by noting the date and time of new entries. 10. Recording of change over time is through sequential, dated entries, ie in system functionality, not the record standards themselves. The core clinical headings Core clinical headings for electronic health records Heading Demographic details Reasons for contact Presenting issue Family history Diagnoses Operations and procedures Assessment scales Investigations and results Current problems and issues Patient and carers concerns Medications Allergies and adverse reactions Safety alerts Management plan Information given Relevant legal information This would include reasons for admission, referral, attendance or encounter. Includes patient s reason. The health problems and issues experienced by the patient resulting in their hospital admission, eg chest pain, blackout, fall, a specific procedure, investigation or treatment. The patient-reported symptoms and issues in relation to the current admission/referral/contact. This section includes all diagnoses. Relevant therapeutic operations and procedures, including any complications and adverse events arising during the procedure. Standardised scales that indicate, for example, severity of illness, physical and cognitive function, pain, Glasgow Coma Scale (GCS), MUST, etc. The relevant investigations performed and their respective results, where present. This includes the result value, with unit of observation and reference interval, where applicable. Problems requiring health or social care services or carer attention. The record of the patient s comments related to their perceptions of their symptoms, their wishes and goals related to their health and their perceptions of their anticipated treatment (which may influence treatment). A list of all prescribed or non-prescribed (eg over-the-counter) current medications. Allergies, drug allergies and adverse reactions. Significant risk of an unfavourable event occurring, including any clinical alerts, vulnerable adult/child. Including planned investigations and treatment for a patient s identified conditions and priorities. Information and advice given directly to the patient, carer and/or authorised representative. Includes mental capacity, advanced decisions about treatment, lasting and enduring power of attorney or deputy and organ donation. To include the location of the relevant documents. The four nation descriptions may vary. Royal College of Physicians and Crown Copyright

6 s within the core clinical headings The following fields should be populated or displayed for the core clinical headings: Demographic details Patient NHS number This is the national unique identifier. Eg in Scotland it is the CHI number Patient name Date of birth Gender Reasons for contact Reason for contact Contact type Coded expression(s), which may include disease state, medical condition, responses and reactions to therapies. For example, colles fracture and lives alone without social support; elective left hip replacement, etc. The intent is to use codes wherever possible but can be free text. To include the reason for contact and the owner of the reason (ie the patient s reason for contact/professional s reason for contact) Admission, referral, handover, discharge, outpatients, etc Presenting issue Presenting issue (each one) These include symptoms, disease state, medical condition, responses and reactions to therapies. The intent is that eventually codes will be used wherever possible but can be free text or image(s). Family history Family history The record of relevant illness in family relations deemed to be significant to the care or health of the patient, including mental illness and suicide Diagnoses Diagnosis (each one) Episode (first, new, other, ongoing) Date diagnosis made Date of first presentation Diseases, disorders, syndromes and physiological states such as pregnancy that can be coded First episode New episode Other, past or ongoing episode The date when the diagnosis was made. This may be generated by the system. The date the diagnosis condition first presented. This may be generated by the system. Royal College of Physicians and Crown Copyright

7 Operations and procedures Operation or procedure (each one) Date procedure performed Complications related to procedures Specific anaesthetic issues The therapeutic procedure performed. This could include the site and should include laterality where applicable. The intent is to use codes wherever possible but can be free text or image(s). The start date and optionally time when the procedure was performed Details of any intra-operative complications encountered during the procedure, arising during the patient s stay in the recovery unit or directly attributable to the procedure. The intent is to be free text but use codes wherever possible. May also be image(s). Details of any adverse reaction to any anaesthetic agents including local anaesthesia, problematic intubation, transfusion reaction, etc Assessment scales Name of scale Scale output Scale date and time For example, New York Heart Failure Scale, Activity of Daily Living (ADL), Cognitive Function Scale, Hospital Anxiety and Depression Scale (HADS), pain scales, Bayley Scales of Infant Development (BSID), Malnutrition Universal Screening Tool (MUST), etc To record the name of the scale and then the score. (An archetype to be used for the breakdown of subscales) Output from each scale/subscale Time and date for each scale/subscale Investigations and results Investigation and results Date investigation performed A description or name of the investigation performed, the result value, with unit of observation and relevant reference interval where applicable. The intent is to use codes wherever possible but can be free text. The date when the investigation was performed. Current problems and issues Problem (each one) Date problem started Can include significant investigation or examination findings. This may be free text, coded or image(s). The date when the problem started. Royal College of Physicians and Crown Copyright

8 Patient and carers concerns Patient s and carer s concerns, expectations and wishes Patients concerns, wishes and goals. This includes information about special communications requests and needs for patients. Also the extent to which the patient wants clinical information to be shared with relatives and others. This could be the carer giving information if the patient is not competent, or the parent of a young child Record if carer has concerns as well. Medications Medication (each one) Medication dose quantity Medication administration description (oral, IM, IV, etc) Medication frequency Medication start date Medication stop date Indication for medication Medication special information Name of the medication (generic name or brand name as relevant) The specified quantity of the prescribed therapeutic agent, such as a drug, to be taken at one time or at stated intervals (from the NHS e- Prescription Service). Includes both value and unit of measure May include method of administration (eg by infusion, via nebuliser, via NG tube) and/or site of use (eg to wound, to left eye, etc). Frequency of taking or administration of the therapeutic agent or medication Date the medication at this dose was first taken by the patient Date the medication at this dose should be stopped The clinical reason for providing the medication. More than one reason may be appropriate for providing a medication. This may include free text or coded diagnoses or problems. Guidance related to medication dose expressed in lay terms. Includes: timing of the dosage (frequency and duration) rate of administration additional information (eg swallow whole, on an empty stomach). This may include compliance eg in relation to steroids and warfarin. Allergies and adverse reactions Allergy/adverse reaction Causative agent Allergies/adverse reaction description eg anaphylaxis, skin rash, etc Date first experienced Allergies, drug allergies or adverse reactions The agent such as food, drugs or substances that has caused or may cause an allergy or adverse reaction in this patient. A description of the manifestation of the allergic or adverse reaction experienced by the patient. This includes the name and may also include the severity of the allergic or adverse reaction which has occurred. Date the allergy or the reaction was first experienced. Royal College of Physicians and Crown Copyright

9 Safety alerts Safety alert (each one) risk to self, risk to others, vulnerable adult/vulnerable child free text description of what the risk or warning is eg a threat to patient or clinician safety, a disease diagnosis, a family history, etc. Management plan Management plan Actions (each one) Person responsible (for each one) Including planned investigations and treatment for a patient s identified conditions and priorities Requested or planned actions to be carried out. This may be free text or coded. Person responsible for carrying out the proposed action or plan Information given Information/advice given to the patient Information/advice given to the carer and/or authorised representative Recipient name Relationship to patient The verbal or written information or advice given to the patient. May include advice about actions related to medicines or other ongoing care activities. The verbal or written information or advice given to the authorised representative such as relatives and carers. Differentiation is required between information given to patients, carers and any other authorised representatives. May include advice about actions related to medicines or other ongoing care activities The name of the person who received verbal or written information or advice The relationship of the recipient to the patient Relevant legal information Mental capacity Advance decisions about treatment Lasting or enduring power of attorney, parent/parental responsibility Organ donation Other matters relating to treatment The mental capacity of the patient to make decisions about treatment etc. Example, where an Independent Mental Capacity Advocate (IMCA) is required for decisions relating to discharge destination, medical treatment, ability to consent etc. Who is the patient s advocate? Written documents completed and signed when a person is legally competent, that explain a person s medical wishes in advance, allowing someone else to make treatment decisions on his or her behalf late in the disease process and the location of these documents. If there is a lasting power of attorney, who is this person or their deputy. In relation to children matters related to parental responsibility are recorded here. Has the person given consent for organ donation? To include the location of the relevant information/documents Any additional matters relating to treatment including competency, consent to treatment and disclosure (eg in the case of children), and any relevant flags/markers Royal College of Physicians and Crown Copyright

10 Appendix 1 The development of the core clinical headings Review of evidence on core clinical headings for electronic health records was completed in June This was informed by discussions with: Information Standards Board (ISB) Department of Health Informatics Directorate (DHID) clinical division NHS Connecting for Health (CFH) Technical Office Common User Interface (CUI) Logical Record Architecture programmes (LRA) Representatives from electronic health record system suppliers. These discussions served to identify the key requirements for clinical and technical definitions that would enable informaticians and system suppliers to unambiguously code the prioritised headings in Electronic Health Record (EHR) applications. This resulted in a Core clinical headings summary paper. The Core clinical headings summary paper was presented to the Core Headings Project Workshop on 7 July Analysis of the workshop output and LRA work informed a draft of Core clinical headings and definitions (Draft 1). These core clinical headings and definitions were reviewed by the project board on 13 July 2011, revised (Draft 2), and then opened to consultation via an online survey, which ran from 21 September 2011 until 13 October Analysis of the consultation survey s quantitative/numerical data and qualitative/comments led to a further revised set of Core clinical headings and definitions (Draft 3). These were reviewed by the project executive board in November 2011 (resulting in Draft 4). An important message emerged from the consultation survey that many respondents were confused about the role of core clinical headings, assuming that these represented information to be recorded at every clinical contact. This is not what is intended and would be burdensome and unnecessary in many circumstances. In order to address this matter, principles for the core clinical headings were drafted and presented to the Second Core Headings Project Workshop on 25 January 2012 along with the revised Core clinical headings and definitions (Draft 4). Analysis of the workshop output informed the final draft of Core clinical headings and definitions (Draft 5). The revised Core clinical headings and definitions were sent to all medical royal colleges, specialist societies and the professional bodies of the other clinical disciplines for final comments on 24 February A final draft of the principles underpinning the core headings was circulated in response to questions on their implementation and use. On 2 August 2012, the final draft version including the headings and the underpinning principles was sent to all the medical royal colleges, specialist societies and professional bodies of the other clinical disciplines for final sign-off. This resulted in a further few minor amendments to some headings. The Core clinical headings for electronic records are consistent with the Vision for patient focussed records. 1 They will be published in 2013 in a full compendium of record standards developed in the programme, together with technical definitions to support implementation in EHR systems. 1 Royal College of Physicians and Crown Copyright

11 Appendix 2 Organisations contributing to core clinical headings The organisations whose representatives and membership contributed to the development of the core clinical headings are listed on the table below. Organisations Association for Clinical Biochemistry Association for Palliative Medicine of Great Britain and Ireland Association of British Clinical Diabetologists Association of Surgeons of Great Britain and Ireland British Association for Parenteral and Enteral Nutrition British Association for Sexual Health and HIV British Association of Audiovestibular Physicians British Association of Dermatologists British Association of Paediatric Surgeons British Association of Stroke Physicians British Association of Urological Surgeons British Cardiovascular Society British Dietetic Association British Geriatrics Society British Orthopaedic Association British Society for Gastroenterology British Society for Haematology British Society for Immunology British Society of Rehabilitation Medicine British Thoracic Society Clinical Genetics Society College of Emergency Medicine College of Occupational Therapists ENT-UK Faculty for Occupational Medicine Faculty of Sport and Exercise Medicine Health Professionals Council Nursing and Midwifery Council Nutrition Society Renal Association Royal College of Anaesthetists Royal College of General Practitioners Royal College of Nursing Royal College of Obstetricians and Gynaecologists Royal College of Opthalmologists Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Physicians and Surgeons Glasgow Royal College of Physicians Edinburgh Royal College of Psychiatrists Royal College of Radiologists Royal College of Surgeons of Edinburgh Royal Pharmaceutical Society of Great Britain Society of British Neurological Surgeons Royal College of Physicians and Crown Copyright