Healthy Child Programme: final report

3.3. Existing Record Headings Amended for Child Health Use Case (page 15 of 5) in 3. Recommendations (chapter 5 of 9) within Healthy Child Programme: final report

This section contains existing headings which have been amended for the child health use case.

3.3.1 Individual requirements

Following the consultation the project team recommended the following headings and definitions are used to record the individual requirements a child or their guardian have:

Individual requirements
Child or parent / carer / guardian	An indicator of whether the individual requirement relates to the child or their primary carer.
Individual requirements	Individual requirements that a person has. These may be communication, cultural, cognitive or mobility needs related to themselves or their primary carer.
Accessible information - communication support	Outlines capability and support required in order to in order to provide accessibility, with regard to disability.
Accessible information - requires communication professional	Requirement for a communication professional to be present in order to provide accessibility, with regard to disability.
Accessible information - requires specific contact method	Requirement for a specific contact method in order to provide accessibility, with regard to disability.
Accessible information - requires specific information format	Requires information in a specific format in order to provide accessibility, with regard to disability.
Mobility needs	A child's or their primary carer's personal physical movement between two spaces that achieves participation and a degree of independence.
Cognition	An indicator of cognitive impairment to be considered when communicating related to the child or their primary carer.

3.3.2. Family History

Following the consultation the project team recommended the following headings and definitions are used to record information about family history:

Family history
Condition or diagnosis	The condition or diagnosis in family relations deemed to be significant to the care or health of the child.
Relationship to child	The relationship of the person with the condition to the child.
Maternal or paternal relation	Record of whether the condition or diagnosis was on the mother’s or father’s side of the family, where needed e.g. paternal grandfather.
Comment	Any further textual comment.

The project team recommends that a SNOMED CT shortlist of preferred terms is created for common family history conditions. In line with the findings from the analysis the project team recommends the following conditions to be included in this shortlist:

Mental health problems
Learning disabilities
Eczema
Allergies
Epilepsy
Heart conditions
Hip dysplasia
Hearing deficits
Asthma
Diabetes

The maternity project should consider family history recorded at the maternity booking and how it can be communicated through to the child’s record.

Following the consultation the project team recommend the following headings and definitions are used to record details about the child’s social context:

Social context
Family and household
Household(s) composition	Details of others living in the same household(s) and their relationship with the child.
Other significant individuals	People deemed as key by family and/or healthcare professionals in the child’s life that do not live in the same home(s).
Household(s) environment	Factors in the household(s) which impact the child’s health and wellbeing, to include smoking in the home, alcohol/substance use etc.
Mother’s educational status	The highest educational qualification attained by the child’s mother.
Accommodation status	An indication of the type of accommodation where the child lives. This should be based on the main or permanent residence.
Mother's employment status	The employment status and occupation of the mother.
Father's employment status	The employment status and occupation of the father.
Household social services support	Whether or not any household member had/has social services support.
Personal
Lifestyle	The record of lifestyle choices made by the child which are pertinent to his or her health and well-being, e.g., the record of the physical activity level, pets, hobbies, sexual habits etc.
Smoking	Latest or current smoking status of the child.
Alcohol intake	Latest or current alcohol consumption record of the child.
Drug/substance use	Record of any drug/substance use by the child.
Social circumstances	The record of the child’s social background, network and personal circumstances, e.g., housing, religious, ethnic/spiritual needs and social concerns.

Standards are currently being developed by the University of Birmingham, University Hospital Birmingham and the Royal College of Physician’s Health Informatics Unit for recording the consumption of alcohol and tobacco. Once completed they could provide structured content under these headings.

3.3.4. Assessment Scales

Following the consultation, the project team recommends the following headings and definitions are used to record assessment scales:

Assessment scales
Assessment scale name	The name of the overarching assessment scale used e.g. Bayley, Griffiths, Ages & Stages Questionnaire etc.
Global score	The total global score from the assessment.
Subscale name	The name of the subscale used (where relevant).
Subscale score	The total subscale score from the assessment.
Comment	Supporting text may be given regarding the assessment scale as a whole or a subscale.

3.3.5. Professional Summary

Following the consultation, the project team recommends that the following headings and definitions are used to record a professional summary:

Professional summary
Professional summary	Summary of the encounter. Where possible, very brief. This may include interpretation of findings and results, opinion and specific action(s). Planned actions will be recorded under ‘plan’.

Note that this heading is the same as ‘clinical summary’ included in current PRSB information models, the name and definition have been changed to reflect the fact that the summary might be recorded by a health care professional other than a clinician.

3.3.6. Plan and Requested Actions

Following the consultation the project team recommend the following headings and definitions are used to record a plan and requested actions:

Plan and requested actions
Plan and requested actions	A simple free text description of the plan of action following the contact with the child. This may include actions for the parent, child, healthcare professional (e.g. health visitor) and review details.

Please note that care plans are out of scope of the project.

3.3.7. Legal Information

The project team recommend that the existing PRSB heading of legal information would be used to record the following headings:

Legal information
Local authority	The named local authority.
Looked after child
Looked after child start date	Start date of a ‘looked after child’.
Looked after child end date	End date of a ‘looked after child’.
Child protection plan
Child protection plan start date	Start date of a child protection plan.
Child protection plan end date	End date of a child protection plan.

Implementation guidance should explain that the legal information section covers ‘looked after children’ and children protection plans; both should include the relevant local authority, start and end dates (where end dates are not entered, the plans should be considered still in place). Once end dates have been entered the information should remain on health and care systems for 364 days.

Page last updated: 18 June 2026