Healthy Child Programme: final report

3.4. Previously Developed Record Headings (page 16 of 5) in 3. Recommendations (chapter 5 of 9) within Healthy Child Programme: final report

This section contains headings which have been developed as part of the standards for the structure and content of acute medical records or previous Professional Record Standards Body projects. We propose that these headings be included as part of the child health project standard, however should be amended with child centered examples where appropriate.

3.4.1. Patient Demographics

Patient demographics
Patient name	The full name of the patient.
Patient preferred name	The name by which a patient wishes to be addressed.
Date of birth	The date of birth of the patient (may include time of birth for a child).
Place of birth	The town and country of birth of the patient.
Sex	The person’s phenotypic sex. Determines how the person will be treated clinically.
Gender	As the patient wishes to portray themselves.
Ethnicity	The ethnicity of the patient.
Religion	The religious affiliation as specified by the person.
NHS number	The unique identifier for a patient within the NHS in England and Wales.
Other identifier	Country specific or local identifier, e.g., Community Health Index (CHI) in Scotland.
Patient address	Patient’s usual place of residence.
Patient email address	Email address of the patient.
Patient telephone number	Telephone contact details of the patient. To include, e.g., mobile, work and home number if available.
Communication preferences	Preferred contact method, e.g., sign language, letter, phone, etc. Also preferred written communication format, e.g., large print, braille.

NHS Digital have also created a subset of personal demographics to provide a historical record of demographics. This demographics history aligns with the above model.

3.4.2. GP Practice

GP practice

| GP name | Where the patient or patient’s representative offers the name of a GP as their usual GP. | |---|---| | GP practice details | Name and address of the patient’s registered GP practice. | | GP practice identifier | The identifier of the registered GP practice. |

3.4.3. Problems and Issues

Problems and issues

| Problems and issues | Summary of problems that require investigation or treatment. This would include significant examination findings which are likely to have relevance, yet are not a diagnosis. | |---|---| | Comment | Any further textual comment to clarify, such as statement that information is partial or incomplete. |

Implementation guidance should recommend that coded items (including functional codes) are included in the values for problem and issues.

3.4.4. Examination Findings

Examination findings
Examination	The examination performed, e.g. general appearance, vital signs, mental state, head and neck examination, oral examination, cardiovascular system, respiratory system, abdomen, genitourinary, nervous system, musculoskeletal system, skin. This could include site and must include laterality where applicable.
Examination findings	The record of findings from the examinations performed.

3.4.5. Diagnoses

Diagnoses
Diagnosis/symptom	The diagnosis or symptom identified.
Stage of disease	The stage of the disease where relevant.
Comment	Supporting text may be given covering diagnosis confirmation, active diagnosis being treated.

Implementation guidance should reference the Royal College of Paediatrics and Child Health SNOMED CT terms for childhood disabilities (< target="_blank" href="http://www.rcpch.ac.uk/system/files/protected/page/BACDDTSandExplanatoryGlossaryGovernanceFen2016.pdf">http://www.rcpch.ac.uk/system/files/protected/page/BACDDTSandExplanatoryGlossaryGovernanceFen2016.pdf)

3.4.6. Medications and Medical Devices (this model would be used to record vitamin K administration)

Medications and medical devices
New medications
Medication name	May be generic name or brand name (as appropriate).
Form	Form of the medicinal substance e.g. capsules, tablets, liquid.
Route	Medication administration description (oral, IM, IV, etc.): may include method of administration, (e.g., by infusion, via nebuliser, via NG tube) and/or site of use, (e.g., ‘to wound’, ‘to left eye’, etc.).
Dose directions description	A single plain text phrase describing the entire medication dosage and administration directions, including dose quantity and medication frequency
Dose direction duration	How long to continue dose including do not discontinue. Coded text.
Additional instruction	Allows for: * requirements for adherence support, e.g., compliance aids, prompts and packaging requirements * additional information about specific medicines, e.g., where specific brand required * person requirements, e.g., unable to swallow tablets.
Indication	Reason for medication being prescribed, where known.

Course status	The status of this prescription in an ambulatory (outpatient/GP/community) context.
Start date/time	The date and/or time that the medication course should begin.
End date/time	The date and/or time that the medication course should finish.
Comment/recommendation	Suggestions about duration and/or review, on-going monitoring requirements, advice on starting, discontinuing or changing medication.
Medical devices	The record of dietary supplements, dressings and equipment that the patient is currently taking or using.

3.4.7. Allergies and Adverse Reactions

Allergies and adverse reactions
Causative agent	The agent such as food, drug or substances that has caused or may cause an allergy, intolerance or adverse reaction in this patient.
Description of reaction	A description of the manifestation of the allergic or adverse reaction experienced by the patient. For example, skin rash, swelling at injection site etc.
Type of reaction	The type of reaction experienced by the patient (allergic, adverse, intolerance).
Severity	A description of the severity of the reaction.
Certainty	A description of the certainty that the stated causative agent caused the allergic or adverse reaction.
Evidence	Results of investigations that confirmed the certainty of the diagnosis. Examples might include results of skin prick allergy tests.
Probability of recurrence	Probability of the reaction (allergic, adverse, intolerant) occurring.
Date first experienced	When the reaction was first experienced. May be a date or partial date (e.g. year) or text (e.g. during childhood).

3.4.8. Safety Alerts

Safety alerts
Risks to self	Risks the patient poses to themselves, e.g., suicide, overdose, self-harm, self-neglect.
Risks to others	Risks to care professionals or others.
Risk from others	Details of where a child is at risk from an identified person e.g. family member etc.

Implementation guidance should explain that these headings should be used to record any safeguarding issues which have been identified. These issues must be acted upon by reporting these to the appropriate authority and any significant related actions should be included in the ‘plan and requested actions’ section.

It is important to note that arrangements for communicating safeguarding information are currently under review and hence these requirements may be subject to change.

3.4.9. Clinical Risk Factors

Clinical risk factors
Relevant clinical risk factor	Factors that have been shown to be associated with the development of a medical condition being considered as a diagnosis. E.g. being overweight, smoker, no use of sun screen, enzyme deficiency.
Clinical risk assessment	Specific risk assessments required/undertaken.
Risk mitigation	Action taken to reduce the clinical risk and date actioned.

3.4.10. Information and Advice Given

Information and advice given
	This includes - what information (including health promotional messages) - to whom it was given.
Information and advice given	The oral or written information or advice given to the patient, carer, other authorised representative, care professional or other third party. May include advice about actions related to medicines or other ongoing care activities on an ‘information prescription’. State here if there are concerns about the extent to which the patient and/or carer understands the information provided about diagnosis, prognosis and treatment.

Page last updated: 18 June 2026