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PRSB Record structure and content
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.
|Properties||Prefix: prsb03-Default language: en-GBContains reusable content?The contents of this 'project' are considered suitable for re-use by other projects when this setting is active.Is private?The project is not listed in the menus and ignored in searches when this setting is active. This useful for projects in incubation fase. You may still work in the project based on direct URLsExperimental/Test?Project is experimental or meant to test things rather than aimed at production useNotifier: Determines the project global issue notifier setting (on/off - default is 'on'). Note: changes to this setting are immediately saved.|
|Publication location|| http://pub.art-decor.org/prsb/ |
|Project overview||Project Index|
|Project Last modified||2019-08-22 16:44:51|
|The Professional Records Standards Body|The Professional Record Standards Body (PRSB) W theprsb.org |Author||2018-2019|