Application Functions

AF101

Patient Record Management

Create Patient Record/Register Patient

This is the ability of an application to create a common reference number for a patient record electronically where one did not exist before (confirm this would be via PAS)

AF102

Patient Record Management

Search for Patient Record (local reference)

This is the ability to search for, identify and read an existing patient record according to an internally (within the application) assigned common reference number (identifier).

AF103

Patient Record Management

Search for Patient Record (NHS Number)

This is the ability to search for, identify and read an existing patient record according to the patients NHS Number.

AF104

Patient Record Management

Search for Patient Record (demographics)

This is the ability to search for, identify and read an existing patient record according to demographics information provided by or known about the patient.

AF105

Patient Record Management

Search for Patient Record (location)

This is the ability to identify and read an existing patient record according to information known about the location of the patient eg. ward, clinic, theatre, etc

AF106

Patient Record Management

Add Patient Identifier

This is the ability of an application to associate an additional patient identifier with the patient record to enable automatic patient identifier. 

AF107

Patient Record Management

Search for Patient record (secondary identifier)

This is the ability of an application to search for, identify and read an existing patient record according to a secondary identifier associated with a patient. To enable this functionality the application should be able to integrate with electronic devices used to read secondary identifiers. e.g. barcode scanner.

AF108

Appointments Management

Create Appointment Slot

This is the ability of an application to allow an administrator to create appointment slots for any appointment type).

AF109

Appointments Management

Search and fulfil Appointment Slots

This is the ability of an application to allow appointment slots to be searched via structured appointment data (time/location/clinician etc.) and for an authorised user to be able to book the Appointment slot.

AF110

Appointments Management

Amend Appointment Record

This is the ability of an application to allow an appointment record to be updated or cancelled.

AF111

Appointments Management

Reschedule Appointment

This is the ability of an application to allow cancelled appointments to be rescheduled.

AF112

Appointments Management

Record Appointment Outcome

This is the ability to record to the patient record the clinical outcome of any appointment.

AF113

Appointments Management

Patient Communications

This is the ability of an application to send an electronic notification to a patient (via email/SMS).

AF114

Documentation Provision

Patient Correspondence

This is the ability of an application to generate and send a letter to a patient.

AF115

Appointments Management

Add to Waiting List  (Inpatient and Outpatient)

This is the ability of an application to add a patient to a waiting list so that other scheduling processes can operate.

AF116

Appointments Management

View Waiting List (Inpatient and Outpatient)

This is the ability of an application to hold or see a waiting list (in data format)  so that other scheduling processes can operate.

AF117

Bed Management

Define Bed configuration

The ability to maintain data on what beds are available to be assigned to patients

• Assign bed types to define mode of use

• Configure rules for operation of bed types

AF118

Bed Management

View Bed Availability

The ability to view which beds do not have a patient assigned

AF119

Bed Management

Assign Patient to Bed

The ability to assign a patient to a bed under a particular speciality. The system should be able to flag where a patient has not been assigned to the correct speciality so this can be flagged to clinicians. [estimated length of stay]

AF120

Bed Management

Update Bed Status

The ability to change the status of a bed:

• Mark bed as closed

• Reserve Bed

• Mark bed as occupied

• Mark bed as vacated

• Mark bed as compromised (dirty/infected…)

AF121

Patient Record Management

Patient Record Search

The ability of an application to enable  a clinician to search for a patient record using a combination of coded or structured data held within or linked to the Patient Record.

AF122

Patient Record Management

Link Patient Records

The ability of an application to be able to link Patient records, e.g. Mother to Child

AF123

Patient Record Management

Clinical Form Templates

This is the ability of an application to enable the configuration of clinical forms/clinical note templates to support the capture of clinical data to be  stored against the patient record. This must includes the setting of rules for forms, e.g. mandatory/optional fields.

AF124

Patient Record Management

Clinical Form Objects

This is the ability to be able to re-use the same data objects/attributes across different clinical forms/clinical note.

AF125

Patient Record Management

Clinical Form Pre-Population

This is the ability of the application to be able to pre-populate a clinical form  with existing data taken from a patient record. The system must be able to set data to being read-only where data should not be amended/overwritten.

AF126

Patient Record Management

Clinical Form Prompts

This is the ability of an application to be able to prompt a user to validate that existing pre-populated data is correct or to complete mandatory fields.

AF127

Patient Record Management

Clinical Form Validation

This is the ability of an application to provide data validation on Clinical forms.

AF128

Patient Record Management

Clinical Form Part-Saving

The ability of an application to enable a partially completed form to be saved for completion at a later date.

AF129

Patient Record Management

Audit changes to Clinical Record

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

AF130

Patient Record Management

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

Patient Record Management

Record Clinical Notes

This is the ability to record a new clinical against a a patient record including being able to incorporate additional data from the patient record and tag the source of the data.

AF132

Record Observation

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.

AF133

Patient Record Management

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.

AF134

Patient Record Management

Record Care Plan 

This is the ability to record a new or amended care plan against a a patient record whilst maintaining an history of changes.

AF135

Patient Record Management

Record Allergies 

This is the ability to record a new or updated allergy as structured data against within a patient record whilst maintaining a history of changes.

AF136

Patient Record Management

Record Admission 

This is the ability to record an admission as structured data against a  patient record whilst maintaining a history of changes.

AF137

Patient Record Management

Record Problems/Diagnosis 

This is the ability to record a new or updated problem/diagnosis (conditions/comorbidities) as structured data against patient record whilst maintaining a history of changes.

AF138

Patient Record Management

Record Procedure/Intervention

This is the ability to record an intervention/procedure as structured data against a patient record whilst maintaining a history of changes.

AF139

Patient Record Management

Record Outcomes 

This is the ability to record a patient outcome (PROMS) as structured data against the patient record whilst maintaining a history of changes

AF140

Patient Record Management

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.

AF141

Patient Record Management

Record intake/outtake

This is the ability of an application to be able to record intake/outtake information, e.g. fluid intake  and store against the Patient record.

AF142

Patient Record Management

Record Ceiling of Care

The ability to record patient decisions/ceiling of care as structured data against a patient record whilst maintaining a history of changes.

Includes:
DNACPR (Do not attempt cardiopulmonary resuscitation) 

AF143

Patient Record Management

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.

AF144

Patient Record Management

Access clinical coding lists

The ability to access clinical coding lists whilst recording information at the point of care.

AF145

Patient Record Management

Search clinical coding lists

The ability of the system to display clinical codes that correspond with the characters being typed by Healthcare Professionals at the point of care, and display them for selection.

AF146

Patient Record Management

Translate information into codes

Computer assisted coding - the use of natural-language processing (NLP) with machine learning (ML) to provide or suggest diagnosis and treatment codes to medical coders based on reading and interpretation of clinical documentation. 

AF147

Patient Record Management

Note dictation (voice to text translation)

The ability of an application to allow a clinician to directly dictate notes which will be stored against the Patient record.

AF148

Patient Record Management

Import results/reports from medical devices 

The ability to import data electronically from compatible files and systems.

AF149

Patient Record Management

Derive data and store against Patient record

The ability of an application to be able to calculate derived data, e.g. BMI from Patient Height and Weight and store this against the patient record.

AF150

Patient Record Management

Create audio file

Create an audio file in any format, add relevant metadata to the audio file and store it as part of the patient record.

AF151

Patient Record Management

Save, search and playback audio file

Playback the audio file/s for the selected patient record.

AF152

Patient Record Management

Create video file

Create a video file in any format, add relevant metadata to the audio file and store it as part of the patient record.

AF153

Patient Record Management

Save, search and playback video file

Playback the video file/s for the selected patient record.

AF154

Patient Record Management

Voice recognition (voice to text translation

The ability of an application to capture notes which a clinician has dictated which can be stored against a Patient record.

[Longer term requirement] speech recognition, natural language processing (NLP), artificial intelligence (AI) and machine learning (ML) to automate documentation of the spoken aspects of a clinical encounter. These solutions use ambient listening and speech recognition technology to convert captured audio to text. Relevant information from the clinical encounter is extracted and summarized before being uploaded to the EHR.

AF155

Patient Record Management

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

Patient Record Management

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.

AF157

Patient Record Management

Visualise Patient Data

This is the ability of an application to take a sequence of data recorded in the patient record and present it graphically.

The application must be able to overlap results against standard charts, e.g. UK growth chart.

AF158

Patient Record Management

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.

AF159

Patient Record Management

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

Patient Record Management

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. 

AF161

Patient Record Management

View drill downs

The ability to be able to drill down into specific parts of a clinical record

AF162

Patient Record Management

Intelligent record searching

The ability of an application to be able to present information within a clinical view based upon criteria selected by the user or based upon the profile of the user. This could include:

• Presenting condition

• Patient demographics

• Clinical speciality

The application should apply techniques to improve the relevance of the information presented to a user.

AF163

Bed Management

Ward, Unit or Department View Configuration

This is the ability to configure views for a ward, unit or department. 

AF164

Bed Management

View Ward, Unit or Department Data

This is the ability of an application to generate a patient view by  a specific ward, unit or department.  

AF165

Bed Management

Update Ward, Unit or Department Views

The ability to manually add information to a ward, unit or department view and store this information within the system.

AF166

Bed Management

Generate historical view

The ability of the system to generate a view to represent the state at a particular date/time.

AF167

Consent Management

Record Patient Consent

The ability of an application to allow legal consent for a procedure to be captured via appropriate legal forms.

AF168

Consent Management

Identify relevant risk factors

The ability of an application to identify any risk factors relevant to a patient when undergoing a specific treatment or procedure.
Clinician may need to accept/reject risk factors based on clinical judgement

AF169

Consent Management

Consent Management

The ability of an application to provide links to relevant content including:

• Content related to an operation/procedure to be undertaken by a patient.

• Clinical procedures relevant to Doctors/Nurses

Note: All multimedia content must be supported.

AF170

Documentation Provision

Patient Correspondence