Core Headings Template

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Description: Core headings described in the RCP document

Publet Introduction:

This publet is a machine-readable model of core clinical headings covering SNOME CT items that are priority for inclusion in electronic health records (EHRs). It has been enhanced for OpenClinical.net in order to promote use of a common framework for documenting patient care in structured, machine-readable formats for storage in electronic medical records. The headings are based on a standard developed by the Royal College of Physicians of London and published with the support of the UK Health and Social Care information Centre and Academy of Medical Royal Colleges.  

This machine-interpretable version of the standard provides the clinical record headings and a description of the information that should be recorded under each heading. OpenClinical.net members can import the template into applications where it is envisaged that use of standard clinical data would be desirable. Individual specialties and services will require headings and information in addition to, and different from, the generic data supported by the standard and the template. The additional heading standards will be developed by those specialties and should be accommodated under the generic headings.

This publet focuses on the core headings of the RCP standard but templates for the full standard, covering hospital referral letters, inpatient clerking, handover communications, discharge summaries and outpatient letters, are also available on OpenClinical.net. 



  Information
Guideline objectives

Core clinical headings: these are priority for inclusion in EHRs as they are generally items that are the priority for codign using SNOMED CT.

Not all headings will need to be used in all care settings or circumstances, and the order in which they appear inEHR applications, communications and letters can be agreed by system providers and end users.

Target setting Primary and secondary care
Target users All clinical staff
Overview
Provenance 3. Represents the current consensus about best practice in its focal area
Management
  • Author: Omar Khan
  • Release date: 2013-07-01
  • Status: Draft - Under Review
  • History: Edited on 14/1/2014
Safety case These standards were developed in extensive consultation with representatives from the medical profession and specialist societies; healthcare professionals from multidisciplinary backgrounds; patients; carers and health information technology professionals. Consultations were carried out via online surveys and multi-stakeholder project workshops (www.rcplondon.ac.uk/projects/healthcare-record-standards). The development programme, the Clinical Documentation and Generic Record Standards (CDGRS) programme, was commissioned by the Health and Social Care Information Centre (originally NHS Connecting for Health) in England. It was led by the Health Informatics Unit (HIU) of the Royal College of Physicians, with the aim of producing evidence- and consensus-based national standards for the structure and content of clinical records. The standards have been endorsed as fit for purpose by 50 organisations that give professional leadership to the medical, nursing and clinical professions. They were signed off as fit for purpose for the whole medical profession by the Academy of Medical Royal Colleges in April 2013.
Sources

Standards for the clinical structure and content of patient records, published by the UK Health and Social Care Information Centre and Academy of Royal Colleges of Medicine

References