record keeping

Home Care Best Practice in Record Keeping

The Professional Record Standards Body (PRSB) was founded in 2013 with the purpose of establishing clinical standards for health and care records. These standards are designed to enhance the safety and quality of health and social care by ensuring accurate recording and easy accessibility of essential information.

Since its inception, the PRSB has released a variety of Information Standards that outline the necessary record-keeping details for specific aspects of health and social care. This effort continues with more standards in progress. Notably relevant to the realm of homecare are:

  1. The "About Me" Standard: This standard captures vital information that individuals wish to share with healthcare and social care professionals.

  2. Core Information Standard: This standard defines a set of information that can be shared across different health and care settings, facilitating effective communication among professionals and service recipients.

  3. Diabetes Information Standard: This standard sets guidelines for sharing diabetes-related information across care settings, encompassing data from digital tools like medical devices and apps.

  4. Personalised Care and Support Plan: This standard allows for the exchange of care plans between patients, caregivers, and healthcare professionals involved in a person's care journey. The latest version includes provisions for community mental health planning.

  5. Palliative and End of Life Care Information Standard: This standard outlines the information crucial for an individual's end-of-life care plan, enabling seamless sharing across various services and settings to honor their preferences and needs.

  6. Urgent Transfer from Care Home to Hospital: This standard specifies the necessary information to be provided to hospitals when a resident requires urgent, unplanned care.

  7. Wound Care Information Standard: Recently endorsed by the Homecare Association, this standard defines the content of wound care management records.

Creating an Information Standard involves engaging all relevant stakeholders, such as the public, patients, caregivers, professional organisations, healthcare providers, and more. The PRSB follows a meticulous process, including literature review, stakeholder consultation, endorsement seeking, and piloting to ensure high-quality care records.

The Homecare Association contributes as a member of the PRSB's Advisory Board, offering guidance for the development of Information Standards. These standards are accompanied by Information Standards Notices (ISNs), which mandate compliance with the standards by NHS providers and system suppliers in England. Compliance deadlines are set, and the Care Quality Commission provides guidance to social care providers on best practices, including adherence to these standards.

Software suppliers aiming to be included in NHS England's Assured Solutions List for Digital Social Care must demonstrate conformity with specific standards. Accreditation processes are available for software suppliers to showcase compliance.

The PRSB's website offers comprehensive information on Information Standards, their development, and best practices. These standards represent a significant step towards standardised record-keeping, ultimately benefiting healthcare and social care providers as systems align with these standards over time. It's crucial for providers to integrate these standards into their practices, software acquisitions, and remain vigilant for new standards as they emerge.

For further details, visit the PRSB's website or join us in Care Begins at Home for all the latest information, news and resources for social care.