Structure and content standards for outpatient records and communications

Structure and content standards for outpatient records and communications April 2013 Prepared by the Royal College of Physicians on behalf of the Health and Social Care Information Centre Royal College of Physicians and Health and Social Care Information Centre 2013 0

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 Health and Social Care Information Centre From the 01 April 2013, the Health and Social Care Information Centre became responsible for some of the functions previously undertaken by the Department of Health Informatics Directorate. This included such as the Clinical Data Standards Assurance (CDSA) programme. The CDSA programme brought 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. Citation for this report: Royal College of Physicians. Structure and content standards for outpatient records and communications. London: RCP, 2013. Copyright This document has been prepared by the Royal College of Physicians on behalf of the Health and Social Care Information Centre. Layout and design Royal College of Physicians 2013 Information and content 2013 Health and Social Care Information Centre 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 e mail: enquiries@hscic.gov.uk. 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 www.rcplondon.ac.uk Registered Charity No 210508 Royal College of Physicians and Health and Social Care Information Centre 2013 1

Contents Introduction 3 Methodology 4 Outpatient headings 5 Appendices 15 Appendix 1 Organisations contributing to the outpatient headings project 15 Appendix 2 Outpatient pilot protocol 16 Appendix 3 Outpatient pilot results 22 Appendix 4 Final outpatient template 25 Royal College of Physicians and Health and Social Care Information Centre 2013 2

Outpatient headings: final report Introduction The Clinical Documentation and Generic Record Standards (CDGRS) programme of work was commissioned by the Department of Health Informatics Directorate (DHID). From the 01 April 2013, the Health and Social Care Information Centre (HSCIC) became responsible for some of the functions previously undertaken by the Department of Health Informatics Directorate. This programme of work has been carried out by the Health Informatics Unit (HIU) in three phases, which are: Phase 1: Headings and definitions were developed for admission, handover and discharge records of patients admitted to hospital (published in 2008). Phase 2: Development of standard headings for outpatient documentation, generic editorial principles for professional record keeping standards 1 and prioritised core clinical headings 2 (April 2011 to March 2012). Phase 3: Comprises(i) developing standards for referral letters, (ii) a pilot of the standard outpatient headings developed during phase 2, and (iii) carrying out a review of all the record standards headings including the admission, handover, discharge, outpatient, referral and core clinical headings and associated definitions (April 2012 to March 2013). The standard outpatient headings piloted in phase 3 were developed during phase 2, with extensive consultation with healthcare professionals and patients 3. The primary purpose of the outpatient headings is the outpatient communication between the hospital doctor, the patient and the general practitioner (GP). However, they may be used for other types of outpatient services eg allied health professionals. If they are, not all headings may be appropriate and there may also be additional specialty or service specific headings which would need to be developed by those specialties or services. This document details the piloting of the standard outpatient headings during phase 3. The aims of the pilot were to confirm: The acceptability of the outpatient headings and content items in practice, ie whether or not they were appropriate for recording, communicating and reporting on outpatient consultations, and the usability of the proposed arrangement of the headings in operational use, with both paper and electronic record keeping systems. In addition, the amendments to the standard outpatient headings, resulting from piloting, contributed to the parallel project reviewing all the record standards headings 4. They are consistent with the Vision for patient focussed records. 5 1 Royal College of Physicians. Clinical Documentation and Generic Record Standards Project: editorial principles for the development of standards for the structure and content of health records. London: RCP, 2012 (http://www.rcplondon.ac.uk/resources/editorial-principles). 2 Royal College of Physicians. Clinical Documentation and Generic Record Standards (CDGRS) project: Phase 2. Core clinical headings and definitions. London: RCP, 2012. (http://www.rcplondon.ac.uk/projects/standards-core-clinical-information) 3 Royal College of Physicians. Clinical Documentation and Generic Record Standards (CDGRS) project: Phase 2. Outpatient documents: Types of services and clinical documentation. London: RCP, 2012. (http://www.rcplondon.ac.uk/projects/outpatientrecords) Royal College of Physicians and Health and Social Care Information Centre 2013 3

Dissemination and implementation of the products of the CDGRS programme will be undertaken in a programme of work which will begin once phase 3 has been completed. Maintenance of all professional record keeping standards will be addressed by a new body, the Professional Record Standards Body (PRSB), which was established in April 2013 (www.theprsb.org.uk). We acknowledge and thank the organisations whose representatives and members contributed to the development of the outpatient headings. Representation extended across all the clinical disciplines (listed in Appendix 1). These headings were submitted to the Academy of Medical Royal Colleges (AoMRC) for sign-off in April 2013. The AoMRC were pleased to support the standards as a fundamental catalyst for the sharing of patient data to improve patient care and experience. Methodology These headings were developed using the HIU s process for record standards development 6. The standard outpatient headings developed during phase 2, and the associated templates for recording the clinical information for the initial and follow-up outpatient visits, were presented to a piloting outpatient documentation project workshop on 16 April 2012 7. This workshop aimed to gain advice from a wide range of stakeholders, including healthcare professionals, informaticians, patients, and legal advice, on the design and delivery of the pilot of the standard outpatient headings. The outcome of the workshop was increased clarity with regard to a practical and pragmatic methodology for piloting the outpatient headings. This was developed into a pilot protocol (final protocol found as Appendix 2), detailing the aims of the pilot and how they would be met through the following four avenues of data collection: 1. from the hospital-based clinicians perspective 2. from general practitioners perspective 3. from patients and carers perspective 4. about the outpatient session information section of headings (now known as outpatient details ). Draft versions of the protocol were developed iteratively through discussions with several hospital trusts and specialties and with the CDGRS phase 3 project board on 15 August 2012. The project manager (PM) visited hospital sites interested in taking part in the pilot to ensure that they understood the pilot protocol, and would be able to participate effectively in the pilot. The piloting of outpatient headings was carried out over a period of three months from August to November (17 August to 19 November 2012; 13 weeks); with data collected at the following four sites by the following specialties: 4 Royal College of Physicians. Consistent structure and content standards for admission, handover, discharge, outpatient and referral records and communications. London: RCP, 2013 (http://www.rcplondon.ac.uk/resources/standards-admissionhandover-discharge-outpatient-and-referral). 5 www.rcplondon.ac.uk/policy/improving-healthcare/health-informatics 6 http://www.rcplondon.ac.uk/projects/developing-record-standards 7 Royal College of Physicians. Clinical Documentation and Generic Record Standards (CDGRS) project: Phase 2. Outpatient documents: Types of services and clinical documentation. London: RCP, 2012. (http://www.rcplondon.ac.uk/projects/outpatientrecords) Royal College of Physicians and Health and Social Care Information Centre 2013 4

1. Barnet and Chase Farm Hospitals NHS Trust audiovestibular 2. Homerton breast surgery 3. Mid Cheshire Hospitals NHS Foundation Trust / Leighton Hospital urology 4. Mount Vernon and Harefield Hospitals / East and North Hertfordshire palliative medicine. Data collection by the pilot sites was managed in a systematic and structured way, which included clear document control, and regular monitoring of progress at each site. The PM engaged regularly with these stakeholders to encourage and monitor their involvement in the pilot. Qualitative and quantitative analysis of the data collected during the pilot was completed in December 2012 (results can be found in Appendix 3). This analysis informed the revised set of outpatient headings; which were further informed by the CDGRS phase 3 project board on 6 December 2012. On 7 February 2013, the outpatient headings along with all other reviewed headings for admission, handover, discharge and referrals were sent for review by the medical royal colleges and specialists societies, and the professional bodies for nursing, midwifery, and allied health professionals for their final comments and sign-off. Final comments and feedback from the professional bodies were used to update all of the headings including the final outpatient headings and a template suitable for both the initial and follow-up outpatient visits (Appendix 4). These headings and the related template were submitted for sign-off to: the CDGRS phase 3 executive board on 27March 2013 including sign of by the sponsor (DHID) the CDGRS phase 3 project board on 3 April 2013 and the AoMRC on 24 April 2013. Outpatient headings The outpatient record headings and subheadings have two major components: outpatient details, which record primarily administrative information, and patient related information which includes referral details and clinical information. The outpatient details are those headings which provide the data required to precisely define and manage information about outpatient ambulatory care activity for administrative, managerial and policy performance purposes. The patient related information in the headings listed below are those that consultation has suggested are the most commonly required for an outpatient record. Not all headings in the outpatient record will appear in outpatient communications. The reason for this is that the outpatient communication is sent most commonly to the general practitioners (GPs) and the patients, who will already know much of the information which will be stored in the outpatient record for specific purposes within the secondary care environment. The GP may have communicated this in their referral to the hospital. GPs and patients are not the only recipients of outpatient communications. Other recipients may need additional or fewer headings from the outpatient record. It is important to note that not all outpatient specialties or circumstances will require all of these headings, and they may be presented in a different order to the order presented below. Furthermore, there is specialty specific information that will need to be recorded (e.g. for psychiatry, paediatrics, etc), in addition to and different from that listed in the standards, but that information can be accommodated within the proposed standards. A full electronic healthcare record (EHR) should include all the headings listed in the review of all the record standards headings. Any information that has been previously recorded in the full EHR will be Royal College of Physicians and Health and Social Care Information Centre 2013 5

available to the clinician during the outpatient consultation and may not be included in the headings below. One of the generic medical record keeping standards, is that each record entry must have the date and time recorded and the signature of the person making the record. This information should be recorded in an electronic record automatically. It is important to remember that much of the information under the outpatient headings will have been previously recorded in the electronic record and does not have to be entered during the outpatient session eg referral details. We recommend and expect that policy, practice and patient demand will lead to consistency of use of record headings across primary and secondary care. GP practice GP name GP practice details GP practice identifier Where the patient or patient's representative offers the name of a GP as their usual GP. Name, address, email, telephone number, fax of the patient's registered GP practice. National code which identifies the practice. Patient demographics Patient name Date of birth Patient sex Gender Ethnicity NHS number Other Identifier Patient address Patient telephone number Patient email address Communication preferences Relevant contacts The full name of the patient. Also patient preferred name: the name by which a patient wishes to be addressed. The date of birth of the patient. Sex at birth. Determines how the individual will be treated clinically. As the patient wishes to portray themselves. The ethnicity of a person as specified by the person. The unique identifier for a patient within the NHS in England and Wales. Country specific or local identifier eg Community Health Index (CHI) in Scotland. Two data items: *type of identifier *identifier. Patient s usual place of residence. Telephone contact details of the person. To include eg mobile, work and home number if available. Two data items: *type *number. Email address of the patient. Preferred contact method, eg sign language, letter, phone, etc. Also preferred written communication format, eg large print, braille. Eg Next of kin, main informal carer, emergency contact. Including: * full name * relationship (eg next of kin) Royal College of Physicians and Health and Social Care Information Centre 2013 6

* role (eg court appointed deputy) * contact details. Special requirements Special requirements Eg Level of language (literacy); preferred language (interpreter required)/ambulance required/ other transport arrangements required/ any other special requirements. Includes: * preferred language * interpreter required * advocate required * transport required, etc. Participation in research Participation in research This is to flag participation in a clinical trial. This may include whether participation in a trial has been offered, refused or accepted, the name of the trial, drug/intervention tested, enrolment date, duration of treatment and follow-up, and contact number for adverse events or queries. Outpatient details Contact type Consultation method Purpose of contact Patient location Appointment time Time patient seen Time consultation finished Specialty Service Responsible healthcare professional Seen by First contact, follow-up contact. Also scheduled, unscheduled. This is always a coded response. Face to face, telephone, teleconference, etc. Explanatory statement of the purpose of the contact. Eg Unscheduled contact because patient concerned, monitoring, screening, diagnosis, assessment, pre-admission assessment, etc. This is the physical location of the patient. For inpatient, eg, hospital ward, bed, theatre. For ambulatory care, eg, health centre, clinic, resource centre, patient s home. The time the patient was due to be seen. The time the patient was seen. To calculate duration of consultation. Specialties designated by Royal Colleges and Faculties. Eg Orthopaedics, renal medicine, endocrinology, etc. Sub-specialties, treatment functions or services. Eg hand surgery, back surgery, hand clinic, TIA clinic, falls clinic, speech and language therapy, dialysis, family therapy, pre-admission assessment clinic, etc. The name and designation of the consultant, nurse consultant, midwife, physiotherapist, etc. who has overall responsibility for the patient (may not actually see the patient). Doctor, nurse or other healthcare professional who sees the patient. Record the most senior member of staff present (eg ward round or where there is a junior member of staff being supervised by a more senior staff member). Includes: * name * role Royal College of Physicians and Health and Social Care Information Centre 2013 7

Care professional(s) present Person accompanying patient * telephone number. The name and designation of the additional individuals or team members including consultant(s), nurse consultant(s), physiotherapist(s), surgeon(s), social worker(s), etc. Eg Where two or more care professionals are jointly running a session. Includes: *name *role *ID. Identify others accompanying the patient eg relative, friend, informal carer, advocate. If the patient was not present was an authorised representative present? Includes: * name * relationship (spouse, etc) * role (patient advocate, etc). Referral details Referrer details Referral method Referral to Urgency of referral Name, designation, organisation and contact details of referrer. If not an individual, this could be, eg, GP surgery, department, specialty, subspecialty, educational institution, mental health etc. Also needs to include self-referral. A method of referral is the form in which a referral is sent and received. This may be a letter, email, transcript of a telephone conversation, Choose and Book, in person (self-referral), unknown etc. Name, designation and organisation. If not an individual, this could be a service, eg, GP surgery, department, specialty, subspecialty, educational institution, mental health etc. Referrer s assessment of urgency (eg urgent/ soon/ routine). May include reason if other than routine. Eg two data items: * level of urgency * reason History Reason for referral Patient's reason for referral Presenting complaints or issues History of each presenting complaint or issue A clear statement of the purpose of the person making the referral eg diagnosis, treatment, transfer of care due to relocation, investigation, second opinion, management of the patient (eg palliative care), provide referrer with advice / guidance. This may include referral because of carers' concerns. Patient stated reason for referral. This may include any discussions that took place, the level of shared decision making involved, information about patient s source of advice. This may be expressed on behalf of the patient eg by parent or carer. The list and description of the health problems and issues experienced by the patient resulting in their attendance. These may include disease state, medical condition, response and reactions to therapies. Eg blackout, dizziness, chest pain, follow-up from admission, falls, a specific procedure, investigation or treatment. Information directly related to the development and characteristics of each presenting complaint(eg including travel history). Including if the information is given by the patient or their carer. Royal College of Physicians and Health and Social Care Information Centre 2013 8

History since last contact Information brought by patient Relevant past medical, surgical and mental health history History since last attendance, discharge from hospital, etc. Eg, Patient Passport, example diary data, pre-completed questionnaire, etc. The record of the patient's significant medical, surgical and mental health history. Including relevant previous diagnoses, problems and issues, procedures, investigations, specific anaesthesia issues, etc (will include dental and obstetric history). Safety alerts Risks to self Risks to others Risks the patient poses to themself eg suicide, overdose, self-harm, self-neglect. Risks to care professional or third party. Medications and medical devices Medication name Medication form Route Dose Medication frequency Additional instructions Do not discontinue warning Reason for medication Medication recommendations Medication change Reason for medication change Medicine administered Reason for non-administration Relevant previous medications Medical devices May be generic name or brand name (as appropriate). Eg capsule, drops, tablet, lotion etc. Medication administration description (oral, IM (intramuscular), IV (intravenous), etc): may include method of administration, (eg, by infusion, via nebuliser, via NG (nasogastric) tube) and/or site of use (eg, to wound, 'to left eye', etc). This is a record of the total amount of the active ingredient(s) to be given at each administration. It should include, eg, units of measurement, number of tablets, volume/concentration of liquid, number of drops, etc. Frequency of taking or administration of the therapeutic agent or medication. Allows for: * requirements for adherence support, eg, compliance aids, prompts and packaging requirements * additional information about specific medicines, eg where specific brand required * patient requirements, eg, unable to swallow tablets. To be used on a case-by-case basis if it is vital not to discontinue a medicine in a specific patient scenario. Reason for medication being prescribed, where known. Suggestions about duration and/or review, ongoing monitoring requirements, advice on starting, discontinuing or changing medication. Where a change is made to the medication, ie one drug stopped and another started or, eg, dose, frequency or route is changed. Reason for change in medication, eg sub-therapeutic dose, patient intolerant. Record of administration to the patient, including self-administration. Reason why drug not administered, (eg, patient refused, patient unavailable, drug not available). Record of relevant previous medications. The record of dietary supplements, dressings and equipment that the patient is currently taking or using. Allergies and adverse reaction Royal College of Physicians and Health and Social Care Information Centre 2013 9

Causative agent Description of the reaction Probability of recurrence Date first experienced The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient. A description of the manifestation of the allergic or adverse reaction experienced by the patient. This may include: * manifestation, eg skin rash * type of reaction (allergic, adverse, intolerance) * severity of the reaction *certainty * evidence (eg results of investigations). Probability of the reaction (allergic, adverse, intolerant) occurring. When the reaction was first experienced. May be a date or partial date (eg year) or text (eg during childhood). Legal information Consent for treatment record Mental capacity assessment Advance decisions about treatment Lasting or enduring power of attorney or similar Organ and tissue donation Consent relating to child Consent to information sharing Safeguarding issues Whether consent has been obtained for the treatment. May include where record of consent is located or record of consent. Whether an assessment of the mental capacity of the (adult) patient has been undertaken, if so who carried it out, when and the outcome of the assessment. Also record best interests decision if patient lacks capacity. Three items: *whether there are 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 *location of these documents *may be copy of the document itself. Record of individual involved in healthcare decision on behalf of the patient if the patient lacks capacity. This includes: *whether there is a person with lasting or enduring power of attorney, independent mental capacity advocate (IMCA), court appointed deputy *name and contact details for person. Two data items: - has the person given consent for organ and/ or tissue donation (yes/no)? - the location of the relevant information/documents. Consideration of age and competency, including Gillick competency. Record of person with parental responsibility or appointed guardian where child lacks competency. Record of consent to information sharing, including any restrictions on sharing information with others, eg family members, other healthcare professionals. Also use of identifiable information for research purposes. Any legal matters relating to safeguarding of a vulnerable child or adult eg child protection plan, child in need, protection of vulnerable adult. Social context Household composition Lives alone Eg, lives alone, lives with family, lives with partner, etc. This may be plain text. Yes/no/don't know (Y/N/DK). Royal College of Physicians and Health and Social Care Information Centre 2013 10

Lifestyle Smoking Alcohol intake Occupational history Social circumstances Services and care The record of lifestyle choices made by the patient which are pertinent to his or her health and wellbeing eg the record of the patient s physical activity level, pets, hobbies, sexual habits and the current and previous use of recreational drugs. Latest or current smoking observation. Latest or current alcohol consumption observation. The current and/or previous relevant occupation(s) of the patient/individual. This may include educational history. The record of a patient s social background, network and personal circumstances eg housing, religious, ethnic and spiritual needs, social concerns and whether the patient has dependants or is a carer. May include reference to safeguarding issues that are recorded elsewhere in the record. The description of services and care providing support for patient s health and social well-being. 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, genetic information etc. Review of systems Review of systems The clinical review of systems. The record of clinical information gathered in responses to questions to the patient about general symptoms from various physiological systems, including food intake (increasing/decreasing), weight change, swallowing difficulties, mood/anxiety, etc. Patient and carer concerns Patient s and carer's concerns, expectations and wishes Description of the concerns, wishes or goals of the patient, patient representative or carer. This could be the carer giving information if the patient is not competent or the parent of a young child. Royal College of Physicians and Health and Social Care Information Centre 2013 11

Examination findings General appearance Vital signs Mental state Head and neck examination Oral examination Cardiovascular system Respiratory system Abdomen Genito-urinary Nervous system Musculoskeletal system Skin Examination procedure The record of a clinician s first impression assessment including general clinical examination finding, eg clubbing, anaemia, jaundice, obese/malnourished/cachectic, height, weight, etc. The record of essential physiological measurements, eg heart rate, blood pressure, temperature, pulse, respiratory rate, level of consciousness. Use of National Early Warning Score (NEWS) chart where appropriate. Formal mental state examination or general description Eg Depression, anxiety, confusion, delirium. The record of findings from the head and neck examination. The record of findings from the oral examination. The record of findings from the cardiovascular system examination. The record of findings from the respiratory system examination. The record of findings from the abdominal examination. The record of findings from the genito-urinary examination. The record of findings from the nervous system examination. The record of findings from the musculoskeletal system examination. The record of findings from examination of the skin. A procedure completed as part of the examination of the patient. Eg sygmoidoscopy, lumbar puncture, pleural tap, etc. Assessment scales Assessment scales Assessment scales used, eg New York Heart Failure scale, Activities of Daily Living (ADL), cognitive function, mood assessment scales, developmental scales, MUST (nutrition), BPI (pain), etc. Problems and issues Problems and issues Summary of problems that require investigation or treatment. This would include significant examination findings which are likely to have relevance, yet are not a diagnosis. In mental health and psychiatry, this may be the place for formulation. Diagnoses Diagnosis Differential diagnosis Confirmed diagnosis; active diagnosis being treated. Include the stage of the disease where relevant. The determination of which one of several diseases may be producing the symptoms. Royal College of Physicians and Health and Social Care Information Centre 2013 12

Relevant clinical risk factors Relevant clinical risk factors Clinical risk assessment Risk mitigation Factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis/ differential diagnosis. Eg, being overweight, smoker, no use of sun screen, enzyme deficiency, poor sight (can impact on falls), etc. Specific risk assessments required / undertaken, including thromboembolic risk assessment, etc. Action taken to reduce the clinical risk, Including thromboembolic preventative action and date actioned. Clinical summary Clinical summary Narrative summary of the episode. Where possible, very brief. This may include interpretation of findings and results; differential diagnoses, opinion and specific action(s). Planned actions will be recorded under 'plan'. Investigations and results Investigations requested Investigation results Procedures requested This includes a name or description of the investigation requested and the date requested. The result of the investigation (this includes the result value, with unit of observation and reference interval where applicable and date), and plans for acting upon investigation results. These are the diagnostic procedures that have actually been requested (and the date requested). Procedures Procedure Complications related to procedure Specific anaesthesia issues The therapeutic procedure performed. This could include site and must include laterality where applicable. 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 plain text and/ or images but use codes wherever possible. Details of any adverse reaction to any anaesthetic agents including local anaesthesia. Problematic intubation, transfusion reaction, etc. Plan and requested actions Actions Including planned investigations, procedures and treatment for a patient s identified conditions and priorities: *person responsible - name and designation / department / hospital / patient / etc responsible for carrying out the proposed action, and where action should take place Royal College of Physicians and Health and Social Care Information Centre 2013 13

Agreed with patient or legitimate patient representative Next appointment details *action - requested, planned or completed *when action requested for - requested date, time, or period - as relevant *suggested strategies - suggested strategies for potential problems, eg telephone contact for advice. Indicates whether the patient or legitimate representative has agreed the entire plan or individual aspects of treatment, expected outcomes, risks and alternative treatments if any (yes/no). Eg booking follow-up appointment, etc. Information given Information and advice given This includes: - what information - to whom it was given. The oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an information prescription'. State here if there are concerns about the extent to which the patient and/or carer understand the information provided about diagnosis, prognosis and treatment. Person completing record Name Designation or role Grade Specialty Date completed Distribution list Distribution list Other individuals to receive copies of this communication/referral letter. Royal College of Physicians and Health and Social Care Information Centre 2013 14

Appendices Appendix 1 Organisations contributing to the outpatient headings project Organisations Acute and mental health trust medical directors Association for Clinical Biochemistry Association for Palliative Medicine of Great Britain and Ireland Association of British Clinical Diabetologists Association of Cancer Physicians Association of Directors of Adult Social Services 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 Oral and Maxillofacial Surgeons British Association of Otorhinolaryngology British Association of Paediatric Surgeons British Association of Plastic, Reconstructive and Aesthetic Surgeons British Association of Stroke Physicians British Association of Urological Surgeons British Cardiovascular Society British Dietetic Association British Geriatrics Society British Infection Association British Orthodontic Society British Orthopaedic Association British Pain Society British Pharmacological Society British Psychological Society British Society for Gastroenterology British Society for Haematology British Society for Human Genetics British Society for Immunology British Society of Rehabilitation Medicine British Thoracic Society Chronic Pain Policy Coalition Clinical Genetics Society College of Emergency Medicine College of Occupational Therapists Department of Health Informatics Directorate Patients and Public Clinical Division Faculty of Occupational Medicine Faculty of Pharmaceutical Medicine Faculty of Sport and Exercise Medicine Health and Care Professions Council Intensive Care Society Local Medical Committee Chairs National Voices NHS London Nursing and Midwifery Council Nutrition Society Renal Association Royal College of Anaesthetists Royal College of General Practitioners Royal College of Midwives Royal College of Nursing Royal College of Obstetricians and Gynaecologists Royal College of Ophthalmologists Royal College of Paediatrics and Child Health Royal College of Pathologists Royal College of Physicians Royal College of Physicians Patient and Carer Network Royal College of Physicians and Surgeons Glasgow Royal College of Physicians of 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 UK Terminology Centre Royal College of Physicians and Health and Social Care Information Centre 2013 15

Appendix 2 Outpatient pilot protocol Clinical Documentation and Generic Record Standards phase 3 outpatient pilot protocol This document provides a protocol for the outpatients pilot project to help sites plan how they will pilot the outpatient headings. It includes information on the following: 1. aims of pilot 2. how will the aims of the pilot be met? 3a. collecting data from the hospital based clinicians perspective 3b. collecting data about outpatient session information 3c. collecting data from general practitioners 3d. collecting data from patients and carers 4. how the HIU will use the information from this pilot. 1. Aims of pilot Confirm how the outpatient headings and content items work in practice ie are they appropriate for reporting, recording and communicating outpatient consultations. Confirm usability of the proposed arrangement of the headings in operational use, with both paper and electronic record keeping systems. 2. How will the aims of the pilot be met? Through analysis of quantitative and qualitative data collected with help from the sources shown in blue on the flow diagram below (Figure 1) Paper and electronic online tools will be provided to you to help you do this these are detailed in each section 3a to 3d. The means of providing feedback and contacting us will be detailed clearly on these tools including URLs, our contact email address and phone number. Figure 1. Sources of feedback of data/information to the Health Informatics Unit (HIU) Royal College of Physicians and Health and Social Care Information Centre 2013 16

3a. Collecting data from the hospital based clinicians perspective What we can provide you with in order to help you to do this: a copy of the headings you will be piloting a copy of the template that shows the heading information for you to use while dictating or writing letters/communications. The template has the high level headings shown in CAPS. The minimum is to use the high level headings with the appropriate information headings included under them (shown in lower case). You do not need to include all the information headings listed (in lower case). You can include the information headings from the list in your letter if you wish an online form for your overall feedback (see link below) stamped addressed envelopes (SAEs) on request an agreed site/hospital name and the clinic specialty name to be added to all documents, forms and communications related to your piloting of the headings. What we would like you to do: Our HIU headings are to be used throughout the pilot, whether or not outpatient communications are dictated or entered electronically: When you dictate letters please use our template as a prompter/aide memoire to provide the structure of the letter. If you use an electronic system you or your site can set up an electronic template using the HIU headings. Using the high level headings (exactly as worded) is critical but not all the information headings have to be used; only those appropriate to the specialty and session. How many patient contacts? We want you to use our headings for at least one clinic session per consultant taking part in the pilot. If you use the headings in more than one clinic and/or sub-specialty clinics we ask that the template be used by each consultant taking part in each participating sub-specialty clinic. We would be very keen for feedback on more than one clinic session. Please send us the following THREE sets of feedback: 1. anonymised (without patient identifiers) copies of the letters/communications generated using our headings (we can send you SAEs for this purpose). 2. any paper (hard copy) templates, listing the headings, on which you have crossed out the headings you have not used during the clinic session (we can send you SAEs for this purpose). 3. overall feedback on the experience of using the template via a short online questionnaire https://www.rcpworkforce.com/se.ashx?s=253122ac0fdf9e5a (this form is now open and collecting data). [A test version can be found here https://www.rcpworkforce.com/se.ashx?s=253122ac0fdf9e83 PLEASE NOTE: This form will not save any data entered]. The short online questionnaire to provide overall feedback on the usability of the headings includes the following questions: 1. Does this outpatient headings structure work for you? 2. Are there any unnecessary headings? 3. Are there any headings which are unclear or confusing? 4. Was there any information which you found difficult to put under an appropriate heading? 5. Do you think that the clarity of your letter/communication will be improved by using these headings? 6. Do you have any other comments to make about these headings? Royal College of Physicians and Health and Social Care Information Centre 2013 17

3b. Collecting data about the outpatient Session Information Purpose Outpatient activity is important and outpatient services are changing. We have developed headings that define outpatient sessions so that they can be accurately described for outcome effectiveness and management purposes. This is the administrative information that is probably routinely used for managing outpatients. We want to test that our session information headings accurately record the relevant information about outpatients. What we can provide you with in order to help you to do this: a short online questionnaire for administrative staff to complete (see link below). What we would like you to do We would like you to ask you administrative staff to complete a short online questionnaire in relation to each clinic session that participates. This would be only in relation to the headings of session information. We would be very grateful for this data as it will identify the extent to which it is collected and any issues with its collection. Please send us the following feedback Overall feedback on the use of our session information headings by your administrative staff via a short online questionnaire - https://www.rcpworkforce.com/se.ashx?s=253122ac0fdf9e2b (this form is now open and collecting data). [A test version can be found here - https://www.rcpworkforce.com/se.ashx?s=253122ac0fdf9e67 PLEASE NOTE: This form will not save any data entered]. The questionnaire to be completed by the administrative staff includes the following questions: Are the information items listed below routinely recorded? If it is not possible to record one or more of these information items, please state why: contact type method of patient contact purpose of contact patient location date of session time of session appointment time time patient seen and time session finished specialty/specialties specific sub-specialty function responsible healthcare professional / area of responsibility seen by additional healthcare professional(s) source of referral type of referral document who was referral to who was referral from. 1. Are any of the information items listed on the previous screen unclear? 2. Do you encounter any problems recording any of the information items listed on the previous screen? 3. Are there any items missing that would help define outpatient encounters? 4. Do you have any other comments to make about these data items? Royal College of Physicians and Health and Social Care Information Centre 2013 18

3c. Collecting data from general practitioners Purpose To gather general practitioner views on whether receiving outpatient communications using these outpatient headings provides both better quality information, and structured letters/communications from which information could ultimately be automatically incorporated into the GP electronic records. We recognise that getting feedback from GPs may be difficult. What we can provide you with in order to help you to do this: copies of an invitation slip to include in posted communications (on RCP headed paper on request) the text of the invitation slip in electronic format to use with electronic communications. What we would like you to do For every outpatient letter/communication sent to GPs, we would like you to include the invitation slip in paper or electronic form (along with a record of your site/hospital name and the clinic specialty name). The invitation slip will invite GPs receiving your letter/communication to provide feedback on the communication just received. The invitation is short and succinct; including the following text: The questions asked of GPs are as follows: 1. Does the letter/communication contain all the information that you would like about your patient s outpatient appointment? if yes, please add any comments you have about this: if not, what is missing? Is there any other information you would like to have included in the letter / communication? 2. Does the communication/letter contain too much information? if no, please add any comments you have about this: if you think that it contains too much information, what could be omitted? 3. In general, do you think that the structure and content of this letter provide better information than outpatient letters you currently receive? Royal College of Physicians and Health and Social Care Information Centre 2013 19

This short online questionnaire can be found here www.rcplondon.ac.uk/outpatient-gp (this form is now open and collecting data). [A test version can be found here - https://www.rcpworkforce.com/se.ashx?s=253122ac0fdf9e69 PLEASE NOTE: This form will not save any data entered]. 3d. Collecting data from patients and carers Purpose To gather patients and carers views on whether receiving outpatient communications using these outpatient headings provides better quality information. We recognise that getting feedback from patients and carers may be difficult. What we can provide you with in order to help you to do this: copies of an invitation slip to include in posted communications (on RCP headed paper on request) the text of the invitation slip in electronic format to use with electronic communications. What we would like you to do For every outpatient letter/communication to patients and carers, we would like you to include the invitation slip in paper or electronic form (along with a record of your site/hospital name and the clinic specialty name). This Invitation slip will invite patients and carers receiving your letter/communication to provide feedback on the communication just received. This invitation will be short and succinct including the following text: The questions asked of patients and carers are as follows: Royal College of Physicians and Health and Social Care Information Centre 2013 20

1. Did you understand the letter/communication you received in relation to this questionnaire? 2. Did the structure of the letter make it easier to understand? 3. Does the letter/communication have all the information you would like about your outpatient appointment? if yes, please add any comments you have about this: if not, what is missing? Is there any other information you would like to have included in this letter? 4. Did the letter contain too much information? if yes, what could be left out? if no, please add any comments you have about this: This short online questionnaire can be found here http://www.rcplondon.ac.uk/outpatient-patient-carer (this form is now open and collecting data). [A test version can be found here - https://www.rcpworkforce.com/se.ashx?s=253122ac0fdf9e36 PLEASE NOTE: This form will not save any data entered]. 4. How the HIU will use the information from this pilot 1. We will review all the feedback from the pilot sites, and where amendments to the headings and/or structure are required we will make these. 2. We will send the revised headings to all medical royal colleges and specialist societies for their approval; prior to submitting them to the Academy of Medical Royal Colleges (AoMRCs) for their sign-off. 3. Once the AoMRC has signed off the headings, we will send them to the Department of Health (DH) and they will become the new national standards for recording outpatient information. Royal College of Physicians and Health and Social Care Information Centre 2013 21

Appendix 3 Outpatient pilot results The outpatient headings found in Appendix 1 were piloted during CDGRS phase 3, over a period of three months from August to November (17 August 2012 to 19 November 2012; 13 weeks). All pilot sites helped collect the following four sets of data on the experience of the outpatient headings being used in practice: 1. from the hospital-based clinicians perspective 2. from general practitioners perspective 3. from patients and carers perspective 4. about the outpatient session information section of headings (now known as outpatient details ). This was done through short online questionnaires (see the outpatient pilot protocol in Appendix 4 for details). This data was collected at the following four sites by the following specialties: 1. Barnet and Chase Farm Hospitals NHS Trust audiovestibular 2. Homerton breast surgery 3. Mid Cheshire Hospitals NHS Foundation Trust / Leighton Hospital urology, and 4. Mount Vernon and Harefield Hospitals / East and North Hertfordshire palliative medicine Hospital based clinicians perspective feedback Data was collected from the clinicians who piloted the outpatient headings at the four sites. They were asked whether or not the outpatient headings structure worked for them, while the fourth clinician felt their previous template was more suitable for his specialty (urology). Three out of the four felt they did. They also provided the following comments: some unnecessary and some cause duplications. I have used my own standard headings and an itemised letter for >12 years. My headings work better for urology than yours. However, the (principle) is fine and there's no reason why individual departments/specialities/hospitals/clinicians can't map their preferred terminology to the closest RCP heading so that the data is captured in a more or less uniform fashion but the letters read properly and individuals are not constrained by a 'one size fits all' approach. Mostly was useful, some headings used for first assessment only eg social history, allergies. There are a few that are very rarely used, but might be applicable at times. Outpatient session information headings feedback This data was collected from administrative staff via a short online questionnaire. The four sites were asked whether or not the following information items were routinely recorded. The table below shows that these items were routinely recorded in the majority of cases: Information item Yes No, but it No Royal College of Physicians and Health and Social Care Information Centre 2013 22

(N = 4) could be Contact type 4 0 0 Method of patient contact 3 1 0 Purpose of contact 3 1 0 Patient location 3 1 0 Date of session 4 0 0 Time of session 3 1 0 Appointment time 3 1 0 Time patient seen and time session finished 3 1 0 Specialty/specialities 4 0 0 Responsible healthcare professional / area of responsibility 3 1 0 Seen by 4 0 0 Additional healthcare professional(s) 3 1 0 Source of referral 3 1 0 Who was referral to/from 3 1 0 Yes No, this is not possible No Specific sub-specialty function 3 1 0 Type of referral document 3 1 0 General Practitioners feedback It was only possible to collect this data from two GPs. Feedback was generally positive, as they found the example letters provided by the pilot sites to be of a high quality, as expressed below: These are higher quality than average letters in general the highlighting of the patients concerns is very clear in the latter and actually everything I need is there. With the following specific recommendation made in relation to future implementation guidance for the headings: There are headings included (in the example letters provided by the sites, when there is no information available/applicable, that) tend to clutter and distract from the narrative. It might help readability /make more concise if several of these were to be better suppressed when there is nothing relevant to add. Patients and carers feedback It was only possible to collect this data from three patients; one each recruited through three of the four sites. All three patients felt they understood the letter/communication received. Expressing thoughts such as these: I did, however, although it is more understandable to clinicians and those working in the medical profession. For those who have access to the internet and able to navigate the web, they can easily look up any term they can't understand and find meaningful explanation. It is also excellent to look at one's medical history at a glance. I found the letter too easy to understand [sic]. Royal College of Physicians and Health and Social Care Information Centre 2013 23

All three patients also felt the structure of the letter made it easier to understand, and found the letter/communication to have all the information they would like about their outpatient appointment. As expressed by the following patient: I think it was great to inform the patient with the exact information given to his/her GP. It gives the patient an informed view when discussing matters with the GP. In addition, all three patients felt that nothing seemed to be missing from the communication, and they did not find it contained too much information. As stated by this patient: The information given is just perfect to let the patient know exactly what is what. In fact the more information given, the better for the patient right to know. Sometimes GPs don't have the time to read letters from hospitals, they probably will miss one or two thinks which the patient think is important for him to discuss in the surgery. Royal College of Physicians and Health and Social Care Information Centre 2013 24

Appendix 4 Final outpatient template TEMPLATE FOR AN OUTPATIENT LETTER St. Elsewhere Hospital_ The template includes the headings (left column) and detailed subheadings (right column). The headings reflect standard clinical practice in writing outpatient letters. The subheadings show the information that would be recorded under those headings. Not all outpatient communications will require all of these headings, and they may be presented in a different order to the order presented below. Initially, in practice, the majority of these communications will probably be dictated. As electronic patient recorded are more widely implemented, the information recorded under the subheadings will appear automatically. The template therefore reflects the fundamental, underlying principle of the whole CDGRS programme. That is that information systems should and can be designed to support the way that clinicians and patients interact during the delivery of healthcare. HEADINGS GP PRACTICE PATIENT DEMOGRAPHICS SPECIAL REQUIREMENTS PARTICIPATION IN RESEARCH REFERRAL DETAILS HISTORY SAFETY ALERTS MEDICATIONS AND MEDICAL DEVICES ALLERGIES AND ADVERSE REACTIONS LEGAL INFORMATION SOCIAL CONTEXT s GP name GP practice details GP practice identifier Patient name Date of birth Patient sex Gender Ethnicity NHS number Special requirements Participation in research Referrer details Referral method Reason for referral Patient's reason for referral Presenting complaints or issues History of each presenting complaint or issue Risks to self Risks to others Medication name Medication form Dose Route Medication frequency Reason for medication Medication change Reason for medication change Causative agent Description of the reaction Consent for treatment record Mental capacity assessment Advance decisions about treatment Lasting or enduring power of Attorney or similar Household composition Lives alone Other identifier Patient address Patient telephone number Patient email address Communication preferences Relevant contacts Referral to Urgency of referral History since last contact Information brought by patient Relevant past medical, surgical and mental health history Additional instructions Medicine administered Reason for non-administration Medical devices Relevant previous medications Medication recommendations Do not discontinue warning Probability of recurrence Date first experienced Organ and tissue donation Consent relating to child Consent to information sharing Safeguarding issues Alcohol intake Occupational history Royal College of Physicians and Health and Social Care Information Centre 2013 25

FAMILY HISTORY REVIEW OF SYSTEMS PATIENT AND CARER CONCERNS EXAMINATION FINDINGS ASSESSMENT SCALES PROBLEMS AND ISSUES DIAGNOSES RELEVANT CLINICAL RISK FACTORS CLINICAL SUMMARY INVESTIGATIONS AND RESULTS PROCEDURES PLAN AND REQUESTED ACTIONS INFORMATION GIVEN PERSON COMPLETING RECORD DISTRIBUTION LIST Lifestyle Smoking Family history Review of systems Patient s and carer s concerns, Expectations and wishes General appearance Vital signs Mental state Head and neck examination Oral examination Cardiovascular system Respiratory system Assessment scales Problems and issues Diagnosis Differential diagnosis Relevant clinical risk factors Clinical risk assessment Risk mitigation Clinical summary Investigations requested Investigation results Procedures requested Procedure Complications related to procedure Specific anaesthesia issues Actions Agreed with patient or legitimate patient representative (Y/N) Next appointment details Information and advice given Name Designation or role Distribution list Social circumstances Services and care Abdomen Genito-urinary Nervous system Musculoskeletal system Skin Examination procedure Grade Specialty Royal College of Physicians and Health and Social Care Information Centre 2013 26