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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

STD009 Birth Notifications

STD024 Critical Care Minimum Data Set

STD036 FGM - Information Sharing (FGM-IS) Local System Integration

STD039 Health and Social Care Organisation Reference Data

STD045 Data Security & Protection Toolkit

STD056 National Joint Registry Data Set

STD062 NHS Number

STD064 NHS Number for Secondary Care

STD085 The Core Information Standard

STD116 Personalised Care and Support Plan

STD124 Clinical referral information

CRC-01.2 - Record Security

DCF Core Capability

As a Healthcare or Clinical Professional,

I want the patient record that is digital and delivers patient information at the point of need, only to authorised, staff, care providers, and patient representatives.

So that, my patients record is secure, and only accessed by appropriate roles

Acceptance criteria 1:

Given the need to have a patient record that contains notes, observations and care plans

When made available a the point of care

Then the patient record is only available to authorised staff, care provides and patient representatives

Acceptance criteria 2:

Given the need to Enable strong authentication and identity federation to staff

When the record, functions and data is to be accessed, ensure password-based authentication is not allowed for new clinical systems to reduce security risk and admin burden.

Then the record security is based on configurable, attribute-based access control to functions and data.

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

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:

  • All changes to patient records.

  • Decision support responses

AF129 Audit changes to Clinical Record

The ability of an application to audit all changes to a Patient medical record.

Standards Compliance

Additional Detail

  • The national data opt-out policy was introduced on 25 May 2018, enabling patients to opt out from the use of their data for anything other than their individual care and treatment , for example research or planning purposes, in line with the recommendations of the National Data Guardian in her Review of Data Security, Consent and Opt-Outs.

  • This is a mandatory requirement from 31/08/2022

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