Professional standards are those that registered healthcare professionals are expected to conform to by their regulator. Some professional standards concern how the professional handles information. For example, there is a general professional standard to maintain accurate and complete records about the patient. Another example is the professional recordkeeping standards developed by the Royal College of Physicians Health Informatics Unit.
There are two types of professional standards concerning information, as described below. These can be combined with other standards to specify what inforrmation should be recorded by the person and how this should be encoded in IT. In all cases definitions are crucial to ensure meaning is not confused nor lost.
Information Practice Standards
These standards state how the patient record or communications should be created or added to. They specify when a record should be made, by whom, how it should be made, what general processes of care should be recorded and what distillations of consultations and care periods should be formulated into communications. They also specify practice for sharing, storing, archiving and disposing of records. For example:
- Records should provide a full account of your assessment and the care you have planned and provided (Nursing and Midwifery Council).
- You should make records at the same time as the events you are recording or as soon as possible afterwards (General Medical Council).
Record and Communication Content Standards
These state the information that should be stored in a patient record or communications. They specify the detail of what should be recorded about the clinical management of the patient, including content of communications. They may consist of both structural and content elements, for example:
- General appearance - The record of a doctor’s ‘end of the bed’ assessment including general clinical examination findings, e.g., clubbing, anaemia, jaundice, etc (RCP Admission clerking record).
- Clinical Narrative - Very brief narrative description of the in-patient episode. Should include complications (RCP Discharge summary).