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REF 2014 Impact Case Study: Developing and implementing national standards to improve the structure and content of medical records

John Williams

Swansea University Author: John Williams

Abstract

This REF2014 Impact Case Study describes a programme of research aimed at improving the quality of patient records and the data derived from them. Patient records are the cornerstone of patient care and a rich source of evidence when aggregated. Our research showed that variations in the structure a...

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Published: 2013
URI: https://cronfa.swan.ac.uk/Record/cronfa30521
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Abstract: This REF2014 Impact Case Study describes a programme of research aimed at improving the quality of patient records and the data derived from them. Patient records are the cornerstone of patient care and a rich source of evidence when aggregated. Our research showed that variations in the structure and content of records limit the quality of the data recorded, and we were commissioned to develop national standards for records from evidence and consensus. These standards have been endorsed by: the Department of Health in their Information Strategy; NHS England, to support data for commissioning; the Academy of Medical Royal Colleges, General Medical Council, Care Quality Commission and Robert Francis to improve professional performance, quality of care and patient safety; NHS Litigation Authority to reduce litigation costs; and Academy of Medical Sciences to support the use of routine data for research.
Keywords: patient records; national standards; data quality
College: Faculty of Medicine, Health and Life Sciences