Project Information
Professional Record Standards Body (PRSB) - better records for better care
The PRSB develops national standards for the structure and content of health and social
care records. These cover, for example, hospital referral letters, handover communications,
discharge summaries, and inpatient and outpatient letters.
The standards are currently published in the form of a final report with supporting
documents including: information models and implementation guidance. The information
models are published in the following formats:
- Mind maps
- Microsoft Word Documents and
- Excel spreadsheets
Many of the information models are common across the range of standards we have now
developed, and we needed a tool to support all aspects of managing the models through
their full life cycle including development and maintenance.
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
Properties |
Prefix: prsb03-Default language: en-GB |
Publication location |
Project overview |
http://pub.art-decor.org/prsb/ |
Project index |
Disclaimer |
The content of this publication has been carefully prepared and reviewed. However,
The Professional Records Standards Body does not guarantee the accuracy, completeness
or quality of the information
provided, or that it is up-to-date. Liability claims against The Professional Records
Standards Body in respect of material or immaterial damage caused by the use or non-use
of the information offered or by inaccurate or
incomplete information are in principle ruled out provided that there is no provable
culpable intent or gross negligence on the institute’s part.
|
List of Authors |
- Administrator
- Dr. Kai Heitmann
- Sandip Kaur
- Tom Hobbs
- Martin Orton
- Jan Hoogewerf
- Darren Wooldridge
- Haroldas Petkus
- Nicola Quinn
- Sheena Jagjiwan
- Alannah McGovern
- Kasmyn Chen
- Holly Kearn
- Sarah Jackson
- Annette Gilmore
- James Critchlow
- Ejeh Kingsley
- Max Gattlin
- Fatima Haidaree
- Sharon Hanley
|
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Version Info
Date |
By |
Description |
2021‑08‑28 16:25:59 |
Sandip Kaur |
Official Release: Version 2.0 Core information standard
Updates v 2.0have been made as part
of the logical model project
to:
-
Updated
more succinct
valuesets
for many elements
for mapping to latest release of SNOMED CT, NHS data dictionary
and
to align to
UK core R4 FHIR profiles
-
FHIR Target
added to represent the link to the UK core FHIR R4 where clinical and technical assurance
has taken place
-
Datatypes
added to reflect a logical model
-
Standard JSON extract exported to SPARX
EA
and
UML entity and attribute diagrams developed
-
SNOMED Tags
added in places where
clin
i
cal
agreement of SNOMED CT codes ha
s
taken place to improve interoperability
-
addition of ‘coded’ and ‘free text’ fields for all coded elements, or
-
restructuring (
eg
) ‘Patient Address’ to include elements for each line of the address.
This aligns standards closer to the associated technical specifications and therefore
makes them more implementable.
|
2021‑08‑04 18:13:52 |
Sandip Kaur |
Official Release: Version 2.0 Personalised care and support plan
Updated 2.0 added personal and professional contacts
- structure of needs, goals and concerns
- structured sections to include terminology
- took out procedures and therapies
- added tags for SNOMED CT for About me and structured
|
2021‑05‑18 18:30:57 |
Sandip Kaur |
Official Release: Version 3.1 Community pharmacy standard
Updated due to feedback from NHS digital on sex and gender and value sets for Medication
name and Vaccine product
|
2021‑05‑05 16:26:15 |
Sandip Kaur |
Official Release: Version 3.0 Transfers of care Final draft of transfers of care standards, pre endorsement.
Maintenance release 2 of the transfer of care standards version 3.
Updates to align with more structured sections and updated terminology and classifications.
Also NHS digitals three year standard review as part of the support contract.
|
2021‑04‑26 13:45:58 |
Sandip Kaur |
Official Release: Version 1.4 Personalised care and support plan Issues updated with performing professional and person completing record
|
2021‑04‑21 13:57:55 |
Sandip Kaur |
Official Release: Version 1.2 Urgent transfer from care home to hospital
Name change to urgent transfer from care home to hospital
|
2021‑04‑21 13:02:58 |
Sandip Kaur |
Official Release: Version 1.2
Updated after Sam's comments
|
2021‑04‑12 16:34:15 |
Sandip Kaur |
Official Release: Version 1.3 Personalised care and support plan
Updates to personalised care and support plan from community mental health project
|
2021‑04‑12 12:26:08 |
Sandip Kaur |
Official Release: Version 1.1 Local authority information
Updated version after observations for website viewer
|
2021‑04‑12 11:08:49 |
Sandip Kaur |
Official Release: Version 1.1 Urgent referral and Hospital referral
Updated version after observation update for website viewer
|
2021‑04‑09 18:21:51 |
Sandip Kaur |
Official Release: Version 1.1 About me and Care home information
Updated version after updates and finalisation for website viewer
|
2021‑04‑09 17:07:37 |
Sandip Kaur |
Official Release: Version 2.0 Community pharmacy standard Version 2 of the consolidated community pharmacy standard
|
2021‑03‑07 23:56:39 |
Sandip Kaur |
Official Release: Version 1.0 Health and care integration standards
Updated terminology and classification mappings and proceeded with endorsement
|
2020‑11‑23 16:39:43 |
Sandip Kaur |
Version 1.1 Community pharmacy standard - consolidation and review |
2020‑11‑16 18:55:24 |
Sandip Kaur |
Official Release: Version 0.4 Health and care integration standards Draft models for the health and care integration programme
|
2019‑07‑18 15:27:45 |
Sandip Kaur |
Official Release Version 1a - publication of the core information standard
|
2019‑07‑11 12:44:58 |
Sandip Kaur |
Version 1 - publication of the core information standard. |
|
Data sets, codes, OIDs and Rules: this information is used for rendering and validation
purposes.