Core information standard: CORE INFORMATION STANDARD IMPLEMENTATION GUIDANCE

Key to the proper reading and comprehension of shared information is some understanding of the context in which the data were originally recorded. It is vital for clinical use of the data that all contextual information must be maintained and should not be lost on exchange or import of information. So, for example, where a diagnosis was made during an A&E attendance, the diagnosis should be linked to that A&E attendance.

The core information standard does not define all possible linkages between different components of information e.g. the diagnosis and the attendance. This will be defined in the logical data model, FHIR profiles and in the local shared care records.

However, following consultation and safety case review we arrived at the following key contextual data which need to be shared:

1. ‘Performing Professional’ which has various attributes, name, role, specialty, organisation of the professional that, for example, performed the procedure or administered the vaccination etc. It might be that the actual professional is not known however the organisation and specialty are known and should therefore be included as contextual information.
2. ‘Person completing record’ - which is the person that actually recorded the information and again has various attributes name, role, speciality and organisation and the date that the record was completed.
3. Location - the place in which the activity took place e.g. a procedure was performed.
4. Date - the date on which the activity took place e.g. then date the procedure was performed. In some cases, this would be start and end dates e.g. of child protection plans.

Note that although both ‘Performing professional’ and ‘Person completing record’ contain the element ‘Speciality’ it is recognised that this only applies to some professionals so only needs to be included where relevant.

The principle applied in the information model is that where it is important (from a professional perspective) to know who undertook the activity and who recorded the activity, ‘Performing professional’ and ‘Person completing record’ will be included in the model. For every item of information shared it is important that an audit trail is recorded (even if not explicitly stated in the information model). This is set out below.