ID | CRC |
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Type | Core Requirement |
Status | Alpha |
Release | V3.0 - March 2023 |
Description
Administration and control of the patient record including the creation and management of the record.
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EPR MDF Core Capability | |||
CRC-01.1- Longitudinal Patient Record | |||
As a Clinical Professional, I want a longitudinal patient record that presents all relevant information to authorised staff in an appropriate, locally configurable format, and notifies staff/external systems of key changes (e.g. births and deaths), So that, I see all relevant and up to date information in the patient record. Acceptance criteria 1:Given the need to have a patient record that presents all relevant information When recording patient information in the patient record Then the patient record presents all information in a locally configurable, appropriate form Acceptance criteria 2:Given the need to have a patient record that presents all relevant information When notifying other staff or external systems Then the patient record enables notification of other staff and external systems of key changes (e.g. births and deaths) Acceptance criteria 3:Given the need to have a patient record that presents all relevant information When sharing patient data with appropriate other organisations or systems Then the patient record must include the capability to anonymise, pseudonymize and reidentify the records in the receiving system record as required Acceptance criteria 4:Given the need to have a patient record that presents all relevant information When editing multiple patient records Then the patient record system allows bulk/group records to be updated Acceptance criteria 5:Given the need to have a patient record that presents all relevant information When capturing clinical data Then the patient record system, provides a configurable rules, defined rules and/or shortcuts for the capture of clinical data Acceptance criteria 6:Given the identify a patient using their NHS number When accessing or sharing patient data Then all patient data must be associated with an NHS number Acceptance criteria 7:Given the need to process patient data When accessing or sharing patient data Then all appropriate information governance standards will be adhered to
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Application Function | Description | ||
AF159 Configure Clinical views | This is the ability to be able to configure clinical views to present different information based upon criteria including:
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AF158 View Patient Record (summary) | The ability to present a summary view of a patient record including pertinent information, e.g Did Not Attend (DNA), Allergies etc. | ||
AF155 View Patient Record (current) | This is the ability to view the data and documents added to a patient record as part of the current episode. | ||
AF156 View Patient Record (historic) | This is the ability to view the data and documents added to a patient record as part of a historic episode. | ||
AF161 View drill downs | The ability to be able to drill down into specific parts of a clinical record | ||
AF348 Notify key changes to patient record | The ability of the system to notify staff and other systems of significant changes to the patient record e.g. births and deaths | ||
AF349 Longitudinal access to patient record | The ability of the system to present access to all relevant data about the patient. The data will be presented in an appropriate form given the context in which it is accessed. The appropriately authorised member of staff will be able to navigate to all data that they are authorised to access | ||
AF350 Provide Pseudonymised Patient Data | When sharing data with external systems the system must provide the capability to de-identify, pseudonymize and re-identify records as required | ||
Standards Compliance | |||
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EPR MDF Core Capability | |
CRC-01.4 - Point of Access | |
As a Healthcare or Clinical Professional, I want the patient's record information to be captured at the point of need and, by authorised staff So that, staff do not need to take notes to be added some time later to the patient's record
Given the need to capture patient information When treating or monitoring a patient Then the information is added at the point of care and not at a later date Acceptance criteria 2:Given the need to monitor and track Patient Activation When assessing patient activation Then Patient Activation Measures are supported and integrated into decision support tools Acceptance criteria 3:Given the need for patients and service users to access a patient record When accessing a patient record, they can in a controlled way, update information for their record Additional Detail
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Application Function | Description |
AF326 Maintain Patient Record via Mobile Device | The ability for a user to view/update a Patient medical record via a Mobile Device |
AF130 Maintain Patient Record | The ability for an application to be able to select the appropriate clinical form to record care against the Patient record whilst maintaining a history of changes. |
AF131 Record Clinical Notes | This is the ability to record a new clinical note against a a patient record including being able to incorporate additional data from the patient record and tag the source of the data. |
AF133 Directly record observation from device | This is the ability for the application to accept an observation directly from a clinical device and store this against the patient record whilst maintaining an history of changes. |
AF140 Directly record observation from device | This is the ability of an application to receive and process observations taken from an external device and incorporate into the patient medical record. As part of recording an observation an application must be able to analyse the recorded parameters and provide a prompt to clinicians where these fall outside pre-configured ranges. |
AF270 External Device Integration | The ability to collect medical data from individuals outside of a traditional care setting and incorporate within the patient care record. The data can by collected via by the individual (rekeying data into an App) or directly from a medical device. |
AF132 Record Observation | This is the ability to record a new observation as structured data against a patient record whilst maintaining an history of changes. As part of recording an observation an application must be able to analyse the recorded parameters and provide a prompt to clinicians where these fall outside pre-configured ranges. |
AF276 User Authentication | The ability of an application to verify the identity of the user attempting to access the system |
AF279 Role Based Access Control | The ability to grant/restrict access to functionality of the system based on user rights. |
AF324 Audit access to patient record | The ability of an application to provide comprehensive audit of all user actions including:
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AF129 Audit changes to Clinical Record | The ability of an application to audit all changes to a Patient medical record. |
Standards Compliance | |
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EPR MDF Core Capability | |
Community MDF Core Capability - CO-01.4 Care Coordination (Sharing Records) | |
CRC-01.5 - Sharing Records | |
As a Healthcare or Clinical Professional, I want, to be able to create, amend, display, archive, mark as confidential, merge, unmerge, link, unlink and delete, multimedia (video, Images and audio) including care and treatment plans which can be shared electronically across multiple points of need, care settings and user groups. So that, I can manage care and treatment plans and share them electronically with other health care professionals where appropriate Acceptance criteria 1:Given the user is sharing patient information, When collaborating with other clinical or administrative personnel, Then care and treatment plans can be shared electronically. Acceptance criteria 2:Given the patient is identified using their NHS number, When accessing or sharing patient data, Then all patient data must be associated with an NHS number. Acceptance criteria 3:Given that patient data is being processed, When accessing or sharing patient data, Then all appropriate information governance standards will be adhered to. | |
Application Function | Description |
AF341 Digital Presentation of Handover Data | The system provides a digital presentation of patient data including context as part of a digital handover to enable the sharing of relevant patient data without the need for paper based handover notes |
AF350 Provide Pseudonymised Patient Data | When sharing data with external data the system must provide the capability to de-identify, pseudonymize and re-identify records as required |
Standards Compliance | |
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EPR MDF Core Capability | |
CRC-01.6 - Sharing Records - National Record | |
As a Healthcare or Clinical Professional, I want provision of access, with user and patient context, to summary care records and, integration with the National Record So that, the summary care record can be shared nationally, regionally and locally Acceptance criterion 1:Given the share patient information When creating summary care records (with user and patient context) Then sharing summary care records with the national, regional and local organisations (including National Care Record, when available) Acceptance criteria 2:Given the identify a patient using their NHS number When accessing or sharing patient data Then all patient data must be associated with an NHS number Acceptance criteria 3:Given the need to process patient data When accessing or sharing patient data Then all appropriate information governance standards will be adhered to | |
Application Function | Description |
AF355 Share summary patient data | the system to make summary patient records electronically accessible to services across the Trust and region and with the national care record |
Standards Compliance | |
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EPR MDF Core Capability | |
CRC-01.10 - Real-time Integration | |
As a Healthcare or Clinical Professional, I want a full integration of system information in real time in a format that enables interrogation. and, The data should be appropriately labelled to identify the source and validity of the data. So that, I can view up to date information and be assured of its validity Acceptance criteria 1:Given the need to access up to date patient information When administrating the patient record Then the data is integrated in real-time and labelled (to identify source and validity) Acceptance criteria 2:Given the identify a patient using their NHS number When accessing or sharing patient data Then all patient data must be associated with an NHS number Acceptance criteria 3:Given the need to process patient data When accessing or sharing patient data Then all appropriate information governance standards will be adhered to Additional Detail
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Application Function | Description |
AF356 Integrated use and retrieval of patient data | The solution should be integrated such that data is retrieved at the point of use to ensure only up to date date is presented. This may include on demand retrieval of data from external systems rather than local storage of potentially stale copies |
Standards Compliance | |
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EPR MDF Core Capability | |
CRC-01.11 - Third Party Exporting | |
As a Healthcare or Clinical Professional, I want to export data in an accessible format to authorised third parties And produce hard copy documents with appropriate numbering and watermarks, So that I can share information with third parties who do not necessarily have digital access Acceptance criteria 1: Given a user has the correct permissions, When exporting or printing hard-copy documents, Then the information is in an accessible format and hard copies have numbering and watermarks. Acceptance criteria 2:Given the patient is identified using their NHS number, When accessing or sharing patient data, Then all patient data must be associated with an NHS number. Acceptance criteria 3: Given that patient data is being processed, When accessing or sharing patient data, Then all appropriate information governance standards will be adhered to. Acceptance criteria 4: Given the need to share data with third party systems, When sharing data, Then the appropriate minimum dataset(s) must be used. Additional Detail
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Application Function | Description |
AF341 Digital Presentation of Handover Data | The system provides a digital presentation of patient data including context as part of a digital handover to enable the sharing of relevant patient data without the need for paper based handover notes |
AF350 Provide Pseudonymised Patient Data | When sharing data with external data the system must provide the capability to de-identify, pseudonymize and re-identify records as required |
Standards Compliance | |
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EPR MDF Core Capability | |
CRC-01.12 - Auditing | |
As a Healthcare or Clinical Professional, I want management and audit of the patient record and, entries within the patient record So that, I can monitor access, completeness and synchronisation Acceptance criteria 1:Given the need to manage and audit the patient record When reviewing patient care (e.g. care plans, treatment/medication decisions and allergies etc) Then the access, completeness and synchronisation can be monitored. Acceptance criteria 2:Given the identify a patient using their NHS number When accessing or sharing patient data Then all patient data must be associated with an NHS number Acceptance criteria 3:Given the need to process patient data When accessing or sharing patient data Then all appropriate information governance standards will be adhered to Additional Detail
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Application Function | Description |
AF324 Audit access to patient record | The ability of an application to provide comprehensive audit of all user actions including:
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AF129 Audit changes to Clinical Record | The ability of an application to audit all changes to a Patient medical record. |
Standards Compliance | |
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Applicable Standards |
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The full list of standards applicable to the secondary care setting are contained at the link below The following standards apply more specifically to the requirements on this page
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