Clinical Document Generic Record Standards (CDGRS)

An Introduction

Gurminder Khamba

Healthcare Records

•Healthcare records are written by clinicians to record point of care contact

•Historically paper based

•GMC – aide memoire for clinical care given

•Legal Documents

•Currently information is being recorded in an exponential fashion

•Data needs to be organised and structured.

•We need to be smart about what we want to do

•80% of medical data is unstructured and is clinically relevant.

•This data resides in multiple places like individual records, lab and imaging systems, paper notes, medical correspondence, claims, CRM systems and finance.

•Information needs to be structured and in context

•A family history of cancer is different from a past medical history of cancer

•Work by Health Social Care and Information Centre and the Royal College of Physicians Informatics Unit

•Endorsed and approved by Professional Records Standards Body (PRSB)

•CDGRS is a collection of approved headings which can be used to structure clinical documents

•Consistent use of headings across documents makes access to information easier and coherent

•The headings have been approved for use both in health and social care environments

•The headings have all been allocated SNOMED CT codes in the most recent update

•Coded Headings allow computer systems to find the appropriate information

•Facilitate the flow of information across organisational boundaries.

Many headings are there to order thought and presentation of narrative•But some can specify important

information which is needed in all summary documents▫Referrals▫Discharge Summaries▫Out patient summaries▫Updates and handovers...all have the same recurring core headings

Core Clinical Model

•These are the key core headings which are used to convey meaningful clinical information in a structured fashion

•Information under each heading can be coded or left in narrative form

Core clinical headingsREASON FOR CONTACT text

*PRESENTING ISSUE Text or code (and/or mapped code for CDS)

*DIAGNOSES Text or code (and/or mapped code for CDS)

CURRENT PROBLEMS AND ISSUES Text or code

*OPERATIONS AND PROCEDURES Text or code (and/or mapped code for CDS)

FAMILY HISTORY Text or code

INVESTIGATIONS AND RESULTS Text or code (PBCL or NLMC)

MEDICATIONS Text or code (DM+D archetype)

ALLERGIES AND ADVERSE REACTIONS Text or code (archetype)

RISKS AND WARNINGS Text...needs more professional input

STRUCTURED SCALES Needs further development of outcomes frameworks

MANAGEMENT PLAN text

PATIENT AND CARERS CONCERNS text

INFORMATION GIVEN TO PATIENT text

RELEVANT LEGAL INFORMATION Text and (pointers?)

Apply the core clinical headings to extract key clinical information from...

• Hospital eDischarge Summary (eDS)• Provider Out Patient eDS• Mental Health eDS• Emergency Department eDS• Obstetric eDS• Paediatric eDS

•Consistent Headings and structured information makes the move to an electronic health record easier

•Enables Clinicians to have access to better healthcare data to help improve care.