Professional record standards for electronic record keeping are a fundamental element of successful IT enabled care and interoperability.
In order to record, share and access health data consistently across care settings, the structure and content of electronic health records needs to be standardised. The Professional Record Standards Body (PRSB) produce standards for the way care records should be structured.
The PRSB has published the PRSB Standards for the Structure and Content of Health and Care Records which replaces the Academy of Medical Royal Colleges publication ‘Standards for the Clinical Structure and Content of Patient Records’ published in 2013.
The PRSB standards have been updated to reflect current professional practice and incorporate new or changed structured content resulting from the development of detailed transfer of care standards. They have been developed with input from thousands of professionals from all health and social care specialties, carers and people who access services. They agreed what information is essential to share in order to provide timely, high-quality care efficiently that is well-coordinated and meets an individual’s needs.
This is the first major release since 2013 and PRSB has produced guidance, FAQs and other materials to help organisations and system suppliers replace previous versions of the standards in their information systems.