CIRO - clinical data and patient records

Great record keeping = high quality information and evidence = excellent patient care

Effective clinical record keeping has always been a prerequisite of delivering high quality evidence-based healthcare (1). Delivering safe and efficient patient care depends on having high quality patient records and, therefore, the right information available when clinical decisions are made. New models of care delivery mean that records are of high quality and that they are also fit for sharing.

High-quality electronic records contain all the information needed about a patient’s health to provide good care to that person. This information can be relied upon to make clinical decisions with confidence when it:

• is accurate
• is appropriately and correctly coded
• has the correct context
• contains no inaccurate or data not related to the patient
• is curated to allow all this information to be accessible

Missing, inaccurate, or non-standard information can, however, lead to Inconsistent care, or risk the quality, and safety, of care delivered (2).

Not only do good quality clinical records and data support the delivery of high-quality care, but they are also essential to support other important activities and purposes, including

• Staff reflection, learning and development
• Data sharing and linking with other systems and services
• Audit and evaluation
• Investigations and evidence
• Service commissioning and alternative pathway development
• Clinical decision support
• Research and clinical development

For data to be used effectively in delivering high-quality care, as well as the other uses listed above, it is essential that it is accurate, clear and easily identifiable and reportable. 

This can be better achieved when the data is recorded in the appropriate, structured field, i.e. not a free text one. The free text fields should only be used to provide contextual and supporting information unless an appropriate structured field is not available.

Presenting Condition and Provisional Diagnosis 
Two fields / areas within the ePCR which are currently not being consistently completed are the presenting condition (PC) - 55% completion and the provisional diagnosis (PD) -31% completion. These fields provide the receiving care provider with a high-level indication of what is wrong with the patient and help with next-steps planning. They are also used extensively throughout the Trust and the healthcare network to support reporting and evidence-based decision making.

Here are some examples of how completing free text, rather than the appropriate fields, has impacted the Trust’s ability to provide accurate and reliable data / evidence: 

• During a recent national salbutamol shortage, the Trust was not able to accurately provide details around the number of asthmatic patients it is attending because the Presenting Condition and Provisional Diagnosis fields are at 55% and 31% completion, respectively.
  
  
• The Trust supplies data to NHS England, alongside all other Trusts in England, to support the Ambulance Care Quality Indicator initiative. As a result of the incompleteness of the presenting condition and provisional diagnosis fields, the STEMI ACQI submission has dropped by over 50% and the Stroke submission by a third.

These fields will also soon become part of our national submission to NHS England for the Ambulance Dataset (ADS).

It is important that these fields are always completed, not just the free text.

Support
To support you with this, we are changing some of the terminology:

• Presenting Condition will become Main Symptom 
• Provisional Diagnosis will become Working Impression

We will also be asking the supplier to remove the mandatory function from the free text and apply it to the fields themselves.

We will be providing Operations Officers and Managers with a report, detailing Presenting Condition and Provisional Diagnosis completion rates for their teams.

Thank you for your ongoing support.

_{1 Baylis, J - The importance of good record keeping (medicalprotection.org)}

_{2 NHS England - NHS England » High quality patient records}

 

Feedback:

For any questions or feedback regarding the completion of ePCRs, please email: epcr.feedback@swast.nhs.uk