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Core Information Standard: Reports

Document Management (page 28 of 18) in Clinical Safety Case Report (chapter 3 of 5) within Core Information Standard: Reports

Revision History

Version Date Summary of Changes
0.1 03/07/2019 First draft created by Dr Annette Gilmore (AG)
0.2 08/07/2019 Updated by Dr John Robinson (JR), CSO
0.3 12/07/2019 Updated by Dr Annette Gilmore following meeting with JR
0.4 24/07/2019 Updated following comments from CSC meeting and Hazard log workshop attendees
0.4 09/08/2019 Reviewed and agreed by PRSB Assurance Committee
0.5 06/08/2019 Final edits by Dr John Robinson
0.6 16/08/2019 Edits to include late feedback.
1.0 16/08/2019 Version to distribute to NHS Digital Clinical Safety Team
1.1 30/09/2019 'Sex and Gender Risk mitigated by implementation' - NHSD Clinical Safety Group comments addressed by JR and AG Following advice from NHSD CSG additional information was added to CIS Implementation Guidance (version 1.2) regarding all CIS risks and 'sex' field
1.2 29/09/2020 First draft created by James Critchlow. This is an updated version of the Core Information Standard (CIS) Safety Case, which now includes Digital Social Care Information products made up of an updated standard for "About Me", a standard for the sharing of data from Local Authorities and guidance on which sections of the CIS should be in the Care Homes view.
1.3 07/10/2020 Updated by Dr John Robinson
1.4 29/10/2020 Updated following assurance committee feedback on hazard log
1.5 29/10/2020 Appendix B removed
1.6 09/03/2021 Edits made following feedback from NHS Digital Clinical Safety Team
1.7 06/04/2021 Edits made following feedback from NHS Digital Clinical Safety Team
1.8 28/04/2026 Updated to reflect changes made to the sex and gender data items in the standard.

Reviewed by

This document must be reviewed by the following people:
NameSignatureDate
Clinical Safety OfficerDr John Robinson30/10/2020
PRSB Assurance CommitteePRSB Assurance Committee07/10/2020
Clinical Safety Officer (for review of changes related to changes to sex and gender data items)Dr Steve Bentley28/04/2026

Approved by

This document must be approved by the following people:

NameSignatureDate
Clinical Safety OfficerDr John Robinson30/10/2020
PRSB Assurance CommitteePRSB Assurance Committee07/10/2020
Project BoardProject Board30/09/2020
NHS Digital Clinical Safety GroupNHS Digital Clinical Safety Group01/04/2021
Clinical Safety OfficerDr Steve Bentley28/04/2026

Glossary of Terms

Term / AbbreviationWhat it stands for
CCGClinical Commissioning Group
CISCore Information Standard
COVID-19Coronavirus disease 2019
CPRCardio - Pulmonary Resuscitation
CQCCare Quality Commission
CSCRClinical Safety Case Report
CSGClinical Safety Group
CSMSClinical Safety Management System
CSOClinical Safety Officer
DCBData Coordination Board
dm+dDictionary of Medicine and Devices
EHRElectronic Health Record
EMIS Egton Medical Information Systems
FHIR Fast Healthcare Interoperability Resources
GDPR General Data Protection Regulation
GP General Practitioner
GUI Graphical User Interface
IG Information Governance
IHD Ischaemic Heart Disease
ISN Information Standard Notice
IT Information Technology
KPI Key Performance Indicator
LCR Local Care Record
NHS National Health Service
NHSD NHS Digital
NHSE NHS England
NPSA National Patient Safety Agency
OPCS Office of Population Censuses and Surveys Classification
OTC Over the Counter
PAS Patient Administration System
Patient Subject of the record
PDS Patient Demographic Service
PRSB Professional Record Standards Body
RBAC Role Based Access Control
READ READ - coded thesaurus of clinical terms
SNOMED CT® Systematized Nomenclature of Medicine – Clinical Terms

Page last updated: 28 July 2026