The Professional Record Standards Body (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.
The PRSB eDischarge summary standard detail the headings that must have been implemented by 1 October 2018.
Learn how two hospitals have successfully implemented headings in their eDischarge summaries to ensure consistent recording of information, to improve the quality of information shared with GPs and to enhance audit data.
Read the Papworth Case Study.
Read the Oxleas case study.
If you need support to develop eDischarge summaries, the Royal College of Physicians Informatics Service has a new learning resource which is published on the Professional Records Standards Body website.