CRC

Core Requirement

Published

V3.0 - March 2023

CRC-01.1- Longitudinal Patient Record

CRC-01.2 - Record Security

CRC-01.3 - Role Based Access

CRC-01.4 - Point of Access

CRC-01.5 - Sharing Records

CRC-01.6 - Sharing Records - National Record

CRC-01.7 - SNOMED Coding

CRC-01.8- Audit Trail Codes

CRC-01.9 - Manual Code Override

CRC-01.10 - Real-time Integration

CRC-01.11 - Third Party Exporting

CRC-01.12 - Auditing

CRC-01.13 - Task Management & Medical Spell Checker

CRC-01.14 - Session Persistence

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

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

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

STD021 Compliance with National Data Opt-outs

STD045 Data Security & Protection Toolkit

STD085 The Core Information Standard

STD116 Personalised Care and Support Plan

DCF Core Capability

As a Healthcare or Clinical Professional,

I want the information to be configurable in views according to staff role

So that, staff are presented primarily with information pertinent to their role

Acceptance criteria 1:

Given the need to ensure that staff receive patient information pertinent to their role

When accessing the patient record

Then the only patient record information that is pertinent to the persons role is displayed

Acceptance criteria 2:

Given the need to ensure that staff receive patient information pertinent to their role

When accessing the patient record

Then care provider can sign into the system using a single sign on (SSO) using smart cards (or equivalent technology)

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

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

AF160 Configure default clinical views

This is the ability to enable a user to configure a view when they access a Patient Record including:

Sorting/ordering – re-ordering the sequence of record either chronologically or via any other data grouping

Filtering and grouping – identifying a subset of the record based on the type or value of a data item or a specific date range

The user interface must highlight where views have been configured.

AF352 Configure Role Based Access

Access to specific data within the patient record can be configured by role to ensure only data authorised for the user can be viewed or processed

Standards Compliance

STD045 Data Security & Protection Toolkit

STD116 Personalised Care and Support Plan

DCF Core Capability

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

Acceptance criteria 1:

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

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:

• 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

STD043 Identity Verification and Authentication Standard for Digital Health and Care Services

STD045 Data Security and Protection Toolkit

STD092 OAuth 2.0

STD093 OpenID Connect

DCF Core Capability

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

STD013 Child Protection Information Sharing

STD019 - Emergency Care Data Set

STD031 Digital Maternity Record Standard

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

STD045 Data Security & Protection Toolkit

STD062 NHS Number

STD064 NHS Number for Secondary Care

STD069 Pathology Test and Results Standard

STD085 The Core Information Standard

STD091 Transfer of Care - Acute Inpatient Discharge Standard

STD092 OAuth 2.0

STD093 OpenID Connect

DCF Core Capability

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 criteria 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

STD019 - Emergency Care Data Set

STD045 Data Security & Protection Toolkit

STD056 National Joint Registry Data Set

STD062 NHS Number

STD064 NHS Number for Secondary Care

DCF Core Capability

As a Healthcare or Clinical Professional,

I want, to be able to define rules for SNOMED coding and, I want shortcuts for defined codes

So that, coding of patient data is quick and easy, even in a locally defined context.

Acceptance criteria 1:

Given the need to add SNOMED codes to a patient record

When editing patient records

Then shortcuts for defined SNOMED codes are available

Application Function

Description

AF143 Configure clinical coding lists

The ability to configure lists of pre-structured clinical codes. The pre-configured lists must be able to make available to support any data collection activity, e.g. via drop down lists.

Standards Compliance

STD080 UK Edition SNOMED CT

DCF Core Capability

As a Healthcare or Clinical Professional,

I want an audit trail for coding which allows me to see the previous and original code entry

So that, I can see how the condition has been coded and decide on a more efficient coding scheme

Acceptance Criteria 1:

Given the need to audit coding

When review the patients record

Then the coding contained in the patient record can be audited

Acceptance criteria 2:

Given the need to add SNOMED codes to a patient record

When editing patient records

Then shortcuts for defined SNOMED codes are available

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

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

STD045 Data Security & Protection Toolkit

STD080 UK Edition SNOMED CT

DCF Core Capability

As a Healthcare or Clinical Professional,

I want, The system software to include user support for changing from manual coding to auto SNOMED coding

So that, system users can make the transition simply and easily

Acceptance Criteria 1:

Given the need to override an automatic SNOMED code

When changing the coding in the patient record

Then the autofill generated SNOMED codes can be manually overridden

Acceptance criteria 2:

Given the need to add SNOMED codes to a patient record

When editing patient records

Then shortcuts for defined SNOMED codes are available

Application Function

Description

AF372 Override Clinical Coding

The ability for a user to override the system provided clinical codes

Standards Compliance

STD080 UK Edition SNOMED CT

DCF Core Capability

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

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

STD062 NHS Number

STD064 NHS Number for Secondary Car

DCF Core Capability

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.

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

STD001 - Accessible Information

STD019 - Emergency Care Data Set

STD062 NHS Number

STD064 NHS Number for Secondary Care

STD082

STD086 The Data Security Standards

STD089 Web Content Accessibility Guidelines (WCAG) 2.1

STD104 UK GDPR

STD105 Data Guardian 10 Data Security Standards

DCF Core Capability

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

Application Function

Description

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

STD045 Data Security & Protection Toolkit

STD062 NHS Number

STD064 NHS Number for Secondary Care

STD116 Personalised Care and Support Plan

DCF Core Capability

As a Healthcare or Clinical Professional,
I want automated task management within the workflow and, medical spell checks
So that, data entry into the clinical workflow is easily added to tasks and is understandable

Acceptance Criteria 1:
Given the need to work with the patient record in an efficient manner
When booking, triaging or scheduling orders
Then automated workflow management tools and a medical spell checker are present

Application Function

Description

AF309 Auto-generate Tasks

The ability of the system to auto-generate a set of tasks (including repeating tasks) for a patient based upon a clinical event occurring (e.g. patient admission, patient diagnosis) together with a schedule of when tasks need to be undertaken.

AF373 Medical Spell Checker

The system will provide a medical spell checker

DCF Core Capability

As a Healthcare or Clinical Professional,
I want to be able to return to the patient record context
So that I do not have to search for the patient record after navigating away from the records

Acceptance Criteria 1:

Given the need to return to the place I left in the patient record
When navigating away to another place
Then session is persistent and can return to where I left off

Application Function

Description

AF374 Session Persistence

The system will simplify recalling a recently used patient record by persisting working sessions so that if a user navigates away from the patient record temporarily they can easily return to it without having to search again for the record

The full list of standards applicable to the secondary care setting are contained at the link below

• Secondary Care Standards

The following standards apply more specifically to the requirements on this page

STD009 Birth Notifications

STD021 Compliance with National Data Opt-outs

STD024 Critical Care Minimum Data Set

STD025 Data Security and Protection Toolkit

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

STD080 UK Edition SNOMED CT

STD085 The Core Information Standard