Healthy Child Programme: final report

The Healthy Child Record standard covers, at a summary level, the scope of the Healthy Child Programme and the PCHR. There are other areas that are delivered in community child health which are not covered by this scope and have thus not been fully considered in this project. It is strongly recommended that additional work is carried out to cover these aspects in order to create a complete community child health record standard.

Where information models have already been developed by the PRSB for record structures or communications, these should be used for the child health events, to provide industry with consistent requirements. Similarly, where SNOMED CT subsets have been developed (e.g. RCPCH diagnosis subset) these should be used.

There are a number of previously developed PRSB standards, which will enable information to be shared between professionals and with parents. (See www.theprsb.org/standards) These include the standards for the structure and content of acute medical records and subsequent PRSB projects (e.g. the emergency care discharge summary, hospital discharge summary, outpatient letter standard etc.). Rather than replicating the information models developed for these projects in the current document, the project team recommends that these standards are used for these specific use cases, but are reviewed to incorporate relevant standards (both new and amended) from the Healthy Child Record and Events Specifications. The RCPCH has made a strong recommendation that these information standards are amalgamated with the standards for the structure and content of acute medical records to create a unified standard for child health records.

The consultation recommended lists of common terms to use to record specific conditions (e.g. maternal problems during pregnancy). These terms will be implemented on NHS IT systems using SNOMED CT. The purpose of the lists of terms is to aid quick, consistent and accurate data entry for common conditions. These lists are not comprehensive and it is recommended that if the condition is not represented by one of these terms, NHS IT systems provide a SNOMED CT browser so that clinicians can identify an appropriate term. Common lists of terms have to be subject to change over time and so it is important that they are not hard wired into systems. The UK Terminology Centre (UKTC) should explore ways in which term lists can be created, maintained and disseminated around the NHS, so that changes to these lists can be made on a national basis without individual systems requiring reconfiguration.

Some information from the maternity record forms an essential part of the child health record. This information has been identified by this project, but it is recognised that the primary source of much of this information will be from maternity systems, for which standards are about to be developed. It is recommended that the information models which relate directly to maternity practice are considered in the related maternity project, as the standards have to be consistent from pregnancy through to child birth and the neonatal period. It is also recommended that the following issues identified as being out of scope for the project should be considered as part of the NHS Digital maternity project:

Each documentation entry must have the date and time recorded and the identity of the person creating the documentation. This information should be recorded in an electronic record automatically, by date and time stamping each entry and associating it with the personal identification of the individual recording it. There should also be the ability to record the actual person who undertook the intervention, where required.

The recommendations included in this report relate to the headings and descriptions consulted on by the project team. It does not provide a fully detailed information model; this has been done by NHS Digital, based upon the recommendations. These information models contain additional data items (such as data required for administrative purposes and secondary uses).