Care Record Coordination (CRC)
- Lewis Ford (Unlicensed)
ID | CRC-01 |
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Type | Core Requirement |
Status | Live |
Description
Administration and control of the patient record including the creation and management of the record.
User Stories
EPR MDF Core Capability | |
CRC-01.1- Longitudinal Patient Record | |
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 Supporting information
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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 | |
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EPR MDF Core Capability | |
CRC-01.2 - Record Security | |
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:
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AF129 Audit changes to Clinical Record | The ability of an application to audit all changes to a Patient medical record. |
Standards Compliance | |
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Addition Information - STD021 - Compliance with National Data Opt-outs 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 | |
EPR MDF Core Capability | |
CRC-01.3 - Role Based Access | |
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 Additional Detail
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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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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 | |
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EPR MDF Core Capability | |
CRC-01.4 - Point of Access | |
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
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 Additional Detail
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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:
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AF129 Audit changes to Clinical Record | The ability of an application to audit all changes to a Patient medical record. |
EPR MDF Core Capability | |
CRC-01.5 - Sharing Records | |
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 criterion 1:Given the need to share patient information When collaborating with other clinical or administrative personnel Then care and treatment plans can be shared electronically 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
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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 | |
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EPR MDF Core Capability | |
CRC-01.6 - Sharing Records - National Record | |
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 criterion 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 | |
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EPR MDF Core Capability | |
CRC-01.7 - SNOMED Coding | |
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 | |
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EPR MDF Core Capability | |
CRC-01.8- Audit Trail Codes | |
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
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Application Function | Description |
AF324 Audit access to patient record | The ability of an application to provide comprehensive audit of all user actions including:
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AF129 Audit changes to Clinical Record | The ability of an application to audit all changes to a Patient medical record. |
Standards Compliance | |
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EPR MDF Core Capability | |
CRC-01.9 - Manual Code Override | |
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: 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 | |
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EPR MDF Core Capability | |
CRC-01.10 - Real-time Integration | |
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 | |
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EPR MDF Core Capability | |
CRC-01.11 - Third Party Exporting | |
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 the need to send patient data to a third-party system 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 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 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 | |
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EPR MDF Core Capability | |
CRC-01.12 - Auditing | |
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:
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AF129 Audit changes to Clinical Record | The ability of an application to audit all changes to a Patient medical record. |
Standards Compliance | |
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EPR MDF Core Capability | |
CRC-01.13 - Task Management & Medical Spell Checker | |
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: | |
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 |
EPR MDF Core Capability | |
CRC-01.14 - Session Persistence | |
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 | |
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 |
Applicable Standards |
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The full list of standards applicable to the secondary care setting are contained at the link below The following standards apply more specifically to the requirements on this page
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