DECOR Information for Project: PRSB Record structure and content (prsb03-)

Project Information

Professional Record Standards Body (PRSB) - better records for better care

• Mind maps
• Microsoft Word Documents and
• Excel spreadsheets

Transfers of care

• Admission record: the clinical, professional and personal information recorded in the hospital admission record at the time of admission.
• Handover record: handover of care from one professional or team to another including out of hours handover, or at the weekend.
• Discharge records: the information recorded in all discharge records sent from hospital services (including acute care discharge, mental health discharge and emergency care discharge) to GPs.
• Outpatient letters: the information recorded in an outpatient setting/ appointment including the initial and follow up outpatient visits and information in the outpatient letter sent to the GP and patient.
• Crisis care: the information shared between GPs and primary care with emergency care, ambulance services and community care during an emergency or acute episode.
• Clinical referral information: the information recorded in communication between GPs and consultants, copied to the patient. This may include other types of referrals. (Section Seven)

Integrated care records

• Healthy child record: the information recorded by the multi–disciplinary team on screening tests, immunisations and developmental milestones that should be accessible to ensure that children receive appropriate care.
• Digital care and support plan: the information recorded in a multi–disciplinary care and support plan including clinical, professional as well as the patient’s own preferences and needs.

Additional project information

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