Reflections on The Standards for the Clinical Structure and Content of Patient Records

 

In the previous posts we have looked at the various sections of the Standards for the Clinical Structure and Content of Patient Records (SCSCPR).

Here I will discuss some of my thoughts on the document particularly in relation to related subject areas.

1. PAS systems. There are various degrees of sophistication for electronic systems for managing patient data. At the most basic level there is the Patient Administration System (PAS). The PAS is particularly focused on demographic data. The demographic data features throughout the sections of SCSCPR. However many of the additional headings are more sophisticated and this is where EPR’s come into their own.
2. The NHS number features in the NHS Interoperability Handbook and it is useful to think about how standards such as SCSCPR feed into the current and any future versions of the NHS Interoperability Handbook.
3. SCSCPR has been signed off by a significant number of organisations including Royal Colleges representing many different professional groups
4. SCSCPR specifically reference SNOMED CT® in the core clinical headings section and it is useful to reflect on the increasing significance of SNOMED CT®

What are the Standards for the Clinical Structure and Content of Patient Records?

The standards are a publication of the Health and Social Care Information Centre (now NHS Digital) and the Academy of Medical Royal Colleges and were published in July 2013 (HSCIC, 2017). The standards were prepared by the Royal College of Physicians on behalf of the Health and Social Care Information Centre. The standards were developed for the recording and integration of information in electronic patient records and to facilitate the use of this information for a range of functions including but not limited to commissioning, performance management and research. These standards were referenced in the HSCIC 5-year strategy.

What is the ‘Information and Technology for Better Care’ Paper?

NHS Digital (formerly known as The Health and Social Care Information Centre) published a 5 year strategy in 2015 titled ‘Information and Technology for Better Care’. This document covers a number of areas.

What is the NHS Interoperability Handbook?

There is an NHS interoperability handbook here. This was developed by NHS England, the Health and Social Care Information Centre (now NHS Digital) and the South, Central and West Commissioning Support Unit.

What is SNOMED CT®?

SNOMED CT® is a systematised health terminology used internationally maintained by the International Health Terminology Standards Development Organisation (IHTSDO).

SNOMED CT® Posts

References

https://digital.nhs.uk/article/249/Our-Strategy, accessed 20.4.17

https://www.rcplondon.ac.uk/projects/outputs/standards-clinical-structure-and-content-patient-records, accessed 1.5.2017

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