National Standards for Medical Record Keeping

1. National Standards for Medical Record Keeping Health Informatics Unit Mala Bridgelal Ram Project Manager for Record Standards

2. Overview • Reasons for standardising medical record content • Work of the RCP on standards and related resources • Implementation • Scenario with discharge standards • Audit Tools

3. Why standards for medical notes are important • Increase in volume and complexity of clinical activity – accurate records are crucial • Working time directive for doctors • Shorter hours more handovers (WHO priorities) • Plenty of evidence of poor record keeping • Medical defence organisations case reports • Audit Commission – 1995 and 1999 & Review of PbR • Health Care Commission 2005/6 and 2006/7 • Health Ombudsman Office • Junior doctors moving between hospitals • Having to relearn systems and processes

4. Why standards for medical notes are important • Enabling data extraction • Outcomes • Audit against clinical guidelines and best practice • Routine data to support clinical research • Clinical coding and Payment by Results • Support consultant revalidation processes • Support development of electronic patient records • In 2007 the RCP was first funded by NHS CFH to develop standards for the structure and content of medical records

5. Standards developed by the RCP • Generic Medical Record Keeping Standards • presented as 12 standards applicable to any patient’s medical record • Record Structure and Content Standards for • the hospital Admission record, inpatient Handover (consultant teams & for ‘Out of Hours’), Discharge from hospital record • Outpatient Documentation (Multi-Discip: March 2012) • Standards developed with wide-scale consultation, signed off by the AoMRC in 2008 as fit for purpose on behalf of the medical profession • The standards are being implemented in paper and electronic systems

6. Useful resources • The standards are published in ‘A clinicians guide to record standards- Parts 1&2’ (they are free to download or order copies)

8. Useful resources • These standards are published in ‘A clinicians guide to record standards- Parts 1&2’ (they are free to download or order copies) • Example templates for the admission, handover and discharge records (free to download) • Two E-learning modules hosted on the DH Information Governance Training Tool website for use by clinicians, auditors, coders etc

9. E-learning modules

10. Useful resources • These standards are published in ‘A clinicians guide to record standards- Parts 1&2’ (they are free to download or order copies) • Example templates for the admission, handover and discharge records (free to download) • Two E-learning modules hosted on the DH Information Governance Training Tool website for use by clinicians, auditors, coders etc • Recently published report: Guidance for the use at appraisal and revalidation of evidence of the quality of medical note keeping

11. Implementation • In 2009 we worked with the Audit Commission to implement the standards in one NHS hospital where the record keeping was known to be poor • Short pilot with clinicians, coders and auditors • Introduced admission and handover documents • If clinicians used the standards it would make coding and auditing of notes significantly easier and provide richer data • Working with NHS CFH to implement record standards for 24 hour discharge summary package • Advise individual clinicians, auditors, wards or hospitals- standards in clinical practice, Trust policy

12. Implementation • NHS Litigation Authority • Risk management standards • Care Quality Commission • Standards for registering NHS care providers • Audit Commission • Payment by Results Framework • GMC • Tomorrow’s doctors • National Patient Safety Agency • Clinical incident reports (errors and omissions) • NHS Scotland • Recommended for use in Scotland • Undergrad and Post grad curricula

13. Scenario: A patient admitted to hospital • A 71 year old man with a history of hypertension, ischaemic heart disease and diabetes is admitted to hospital as an emergency with pneumonia. • He is also found to have renal failure. • Treated with IV antibiotics and reviewed by the renal team, who conclude that his renal failure may have been precipitated by the ACE inhibitor he is on. • ? underlying renal artery stenosis and recommend that ACE inhibitors are avoided in future. • He makes an uneventful recovery and is discharged from hospital 5 days later.

15. Two months after that, the patient is re-admitted to hospital having collapsed due to fast atrial fibrillation. Blood tests show acute renal failure with severe hyperkalaemia and metabolic acidosis. The patient requires admission to ITU for urgent dialysis.

17. Audit of the Quality of Patients Notes • With funding from HQIP we are developing 3 web access audit tools based on the • Generic Record Keeping Standards which are applicable to all healthcare professions who record in the patient notes (The generic standards and an example audit tool are referenced by the NHSLA in their 2011 handbook) • Admission Record Standards • Discharge Record Standards

18. Audit Tool- Generic Medical Record Keeping Standards • 2008 audit tool developed as a paper version and then MS Excel within CSD and piloted twice, 16 sites • Junior Doctors, Nurses, Consultants, Auditors (10 sets x3); Piloted with a mixture of specialties including medical, surgical and psychiatric long stay • England, Wales, Jersey • 2009 began dialogue with nursing, midwifery and the allied health professions • 2010 held workshop to refine standards with: British Dietetic Association, British Psychological Society, Chartered Society of Physiotherapy, College of Radiographers, Nursing & Midwifery Council, Royal College of Nursing, Royal College of Speech & Language Therapists, Society of Chiropodists and Podiatrists, Royal Pharmaceutical Society of Great Britain.

20. Audit Tools- Admission & Discharge Standards • Simple audit criteria based on “do you use the recommended standard headings in your admission clerking or discharge documentation”? • These audit tools were piloted in the 2009 project with the Audit Commission- 40 sets pre-implementation and 100 post, by Trust Auditors • 2010 workshop: other clinical disciplines and useful suggestions are now incorporated

22. How are the standards & audit tools being used? • St Helier’s have included the Generic Standards in their trust policy; Audit ½ day with clinicians (doctors and nurses) from all specialties every 6 wks • Uses the Generic Medical Record Keeping Standards Audit Tool and audits 10 sets of notes per specialty; results from 60-80 taken to meeting • Produced macros to amalgamate results for end of year totals • Sections helpful for driving improvement: • List 5 main areas that need improvement • Identify 5 action points to improve the quality of record keeping • Consultants introducing the admission proforma and the auditors will use the admission audit tool

23. How are the standards & audit tools being used? • Royal Cornwall Hospitals NHS Trust has their record keeping policy based on the RCP record standards work • Use Generic Standards audit tool; audits 20 sets of case notes from a mix of specialties once a month, of patients discharged the previous month. • Uses the amalgamation of these audits for CQC and NHSLA purposes • Monthly feedback to Divisional Quality Leads on 5 areas for quality improvement • Setting up a Health Records User Group who will be monitoring quality and to improve reporting system

24. Summary • Reasons for standardising medical record content • Work of the RCP on standards and related resources • Implementation • Scenario with discharge standards • Audit Tools

25. Contact us • Outpatient documentation • Online consultation and 14 Dec workshop. If you would like to be involved please email us • Audit Tools- currently looking for pilot sites • Emailinformatics@rcplondon.ac.uk • Call 0203 075 1578 • Join our register to be kept up-to-date