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CRC-01.1- Longitudinal Patient Record | |||
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DCF Core Capability | |||
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 | |||
STD024 Critical Care Minimum Data Set - ISB 0153 Guidance | |||
STD036 FGM - Information Sharing (FGM-IS) Local System Integration - DCB2112 Guidance (NHS Digital) | |||
STD039 Health and Social Care Organisation Reference Data - DCB0090 Guidance (NHS Digital) | |||
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