Standardised records will improve patient safety throughout their stay in hospital

For the first time, standards for patient records have been developed by the Royal College of Physicians, in partnership with NHS Connecting for Health, and agreed by the Academy of Medical Royal Colleges, representing the whole medical profession.  The new standards will improve patient safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.

For the first time, standards for patient records have been developed by the Royal College of Physicians, in partnership with NHS Connecting for Health, and agreed by the Academy of Medical Royal Colleges, representing the whole medical profession.  The new standards will improve patient safety by standardising the information held on patients throughout their stay in hospital, reducing the likelihood of mistakes and missing information at admission, handover and discharge.

NHS Connecting for Health funded the Health Informatics Unit of the Royal College of Physicians to develop profession-wide standards for the structure of the clinical content of admission records and handover and discharge communications when patients are admitted to hospital.  The prototype standards were then piloted in hospitals, and sent out for consultation to patients, carers, other medical Royal Colleges and specialty societies.  Over 3,000 doctors responded to the consultation on admission records headings, with over 90% agreeing that there should be structured documentation across the NHS.

This development comes at a time when the Healthcare Commission has identified record keeping as one of the weakest areas of NHS performance in its annual health check, with just 85.2% of NHS organisations meeting the standards.

The standards can be used in paper records, or incorporated into online patient record systems such as those run by Cerner and CSC.

Benefits of the standards for structure and content:

    * Standardisation of content will improve safety by reducing opportunities for ambiguity or omission of data

    * Paper proformas can be developed using these standards with confidence that they are likely to reflect best practice

    * Structuring records in this way will help to improve:

          o ease and accuracy in communication of clinical information
          o the quality and safety of clinical practice
          o the accuracy of clinical coding

    * When junior doctors move from one hospital or department to another, they will not need to familiarise themselves with new document structures.

    * Clinical information in electronic records will be recorded once, and made available when needed, thus improve efficiency and save time.

    * Implementation of the new clinical information systems will be simplified, as the systems will all be built on the same professionally developed and agreed structure standards

    * Patients and carers were involved in the development of the standards and their considerations will become better embedded in clinical practice.

    * The Royal College of General Practitioners was consulted and GPs took part in the piloting of the discharge standards.  Discharge summaries based on these standards should deliver the information that they want and need.

    * National audits should be easier to conduct using comparable data from across the country

    * Routine clinical data will better support research.  Both prospective trials and retrospective epidemiological studies will be easier and more cost effective to carry out

    * It is likely that revalidation will include an evaluation of clinical performance with some evidence from medical notes.  Structuring notes using the standards will contribute to a fair evaluation.

Professor Ian Gilmore, President, Royal College of Physicians, said:

"The biggest single factor in delivering high quality, safe healthcare is the timely availability of accurate relevant information about the patient.  I cannot overstate the importance of this vital development in getting that information to the bedside, where it is urgently needed."

Professor Dame Carol Black, Chair, Academy of Medical Royal Colleges, said: At their heart, these standardised records will improve patient safety. They enable a more comprehensive, yet incisive approach to clinical care, with up to the minute recording of the observations and decisions that matter to patients, and must be clear to all at every stage in care. That has to be a good thing and we applaud the work of John Williams and his team in delivering this advanced and challenging project to the medical community.

Professor Michael Thick, Chief Clinical Officer, NHS Connecting for Health, which funded the RCP to draw up the joint standards, said: The recent Informatics Review highlighted the importance of improving information standards across the NHS and the need for clinicians to have the right patient information, at the right time, in order to deliver better, safer care.  Standardising patient records in hospitals will bring enormous benefits, increasing patient safety and providing clinicians with a consistent record structure that supports the treatment of increasingly complex and diverse heathcare needs.

It is absolutely vital that these standards are drawn up by and for healthcare professionals and we welcome the backing of the Academy of Medical Royal Colleges. We must now continue to work closely with a wide range of practitioners to further develop the standards, ensuring that they meet the priorities of different professions, helping to provide the best patient care possible.

Professor John Williams, Director of the RCP Health Informatics Unit, said: This is a real breakthrough.  Standardisation of the clinical content of records will make patient care safer and bring huge benefits for audit and research.  The project has demonstrated how professional leadership can be harnessed to bring benefits for patients, achieving consensus from professionals and incorporating the views and needs of patients.

About NHS Connecting for Health

NHS Connecting for Health was formed as an agency of the Department of Health on April 1 2005. Its purpose is to support the NHS to deliver better, safer care to patients, via new computer systems and services, that link general practitioners and community services to hospitals, and to maintain the national critical business systems previously provided by the former NHS Information Authority.

About the Royal College of Physicians

The Royal College of Physicians of London provides a huge range of services to our 20,000 Members and Fellows and other medical professionals. These include delivering examinations, training courses, continuous professional development and conferences; undertaking clinical audits; publishing newsletters, guidelines and books through to maintaining the College's historical collections. We also lead medical debate, and lobby and advise government and other decision-makers on behalf of our members.