The Health Informatics Unit of the Royal College of Physicians has been pivotal in the development of standards for medical records.  It co-ordinated a project that has produced Generic Medical Record Keeping Standards, and Standards for Content and Structure of inpatient notes that have been jointly published by the Academy of Medical Royal Colleges and the NHS Digital and Health Information Policy Directorate.

http://www.rcplondon.ac.uk/clinical-standards/hiu/medical-records/Pages/Overview.aspx

National Care Records Service

http://www.connectingforhealth.nhs.uk/systemsandservices/nhscrs

HealthSpace

Website providing access to summary care record for patients in England.

https://www.healthspace.nhs.uk/

Good practice and sources of further information

Good practice and sources of further information will be added to during the consultation period.  Reviewers are asked to recommend any additions for consideration.

National Institute for Health and Clinical Excellence

http://www.nice.org.uk/

National Library for Health

http://www.library.nhs.uk/

NHS Connecting for Health Information Quality Assurance Programme (Data Quality)

http://www.connectingforhealth.nhs.uk/systemsandservices/data/dataquality

Secondary Uses Service

http://www.connectingforhealth.nhs.uk/systemsandservices/sus

Sources of legislation, to include:

· the Computer Misuse Act 1990

· the Data Protection Act 1998

· the European Directive on Data Protection

· the Access to Health Records Act 1990

and any subsequent revisions to this legislation.

National Patient Safety Agency

http://www.npsa.nhs.uk/

NHS Information Centre

http://www.ic.nhs.uk/

Information Commissioner’s Office

http://www.ico.gov.uk/

Information Governance Toolkit

https://www.igt.connectingforhealth.nhs.uk/

Information Governance Statement of Compliance

http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/igsoc/links/IG-Statement-of.pdf

National Care Records Service

http://www.connectingforhealth.nhs.uk/systemsandservices/nhscrs

Care Record Guarantee

http://www.connectingforhealth.nhs.uk/crdb/docs/crs_guarantee

Registration Authority

http://www.connectingforhealth.nhs.uk/systemsandservices/rasmartcards/stepguide

Essential IT Skills

Full details of the EITS Programme, including how to access the training can be found at:

http://www.connectingforhealth.nhs.uk/systemsandservices/etd/eits  

What Epidemiological data is currently available?

In the UK, there are currently no routine surveillance systems in place to monitor, in real-time, attendances to EDs and/or emergency admissions.  Hospital admission data are currently available through the Hospital Episode Statistics (HES) database (www.hesonline.nhs.uk) which is a centralised data collection facility covering all NHS and private hospitals in England.  Data from this system are available for use for surveillance activities, however the current availability of these data are not timely and are released with an approximate 6 month delay.  Therefore, for use in a real-time system HES data are not suitable and more likely to be used for retrospective analyses or validation exercises.  There are also costs involved with accessing these data.

 

Other Useful Web Links:

http://www.connectingforhealth.nhs.uk/

Clinical Connections: Connecting for Health Newsletter for clinicians

Payment by results : Department of Health - Policy and guidance 

Casemix Service — Portal