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CRC-01.1- Longitudinal Patient Record

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

Info

Supporting information

  • Patient records must be longitudinal and adhere to the relevant longitudinal patient record standards.

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:

  • The clinical speciality of the user

  • The presenting condition of a patient.

  • Time ranges of search results

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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