GPs have been issued with new guidance on how patient information should be listed in electronic clinical records in order to meet the Government’s pledge for patients to be able to access their GP records online by 2015.
The guidance by the Royal College of Physicians and the Health and Social Care Information Centre (HSCIC) lists requirements to ensure clinical information is recorded in a consistent way, as part of health secretary Jeremy Hunt’s plan for the NHS to go ‘paperless by 2018’.
The Standards for the clinical content and structure of healthcare records guidance says a full electronic record should contain details of GP practice, referral details patient demographics, special requirements, participation in research, relevant clinical risk factors, reason for contact, presenting complaints or issues, history, medications and medical devices, allergies and adverse reactions, safety alerts, legal information, social context, family history, review of systems, patient and carer concerns,
It should also include details of examination findings, assessment scales, problems and issues, diagnoses, procedures, clinical summary, investigations and results, plan and requested actions, outstanding issues, information given, person completing record, person receiving handover, distribution list, the guidance said.
They were developed by consultation with representatives from the medical professionals and specialist societies; healthcare professionals from multidisciplinary backgrounds; patients; carers and health information technology professionals.
A spokesperson for the Royal College of Physicians said: ‘Collecting patient data in this way will deliver improved patient care, high quality patient experience and greater efficiency in terms of management and research in healthcare.’
Dr Mike Farrar, chief executive of the NHS Confederation, said: ‘The NHS has done a lot of work to switch to a paperless service with impressive results, but such initiatives are patchy.
‘What we really need is a programme that joins up the whole system, one that is accessible no matter which NHS service is treating you and one that frees up more clinicians’ time and patients’ time to focus on care.’