HEALTH RECORD KEEPING POLICY. Documentation Control

Transcription

1 Documentation Control Reference: Approving Body: TRUST BOARD Date approved: Implementation date MARCH 2010 Version: 2 Supersedes NUH VERSION 1 (MARCH 2007) Consultation HEALTH RECORDS MANAGEMENT GROUP undertaken: Date of Completion JANUARY 2010 of Equality Impact Assessment Target Audience ALL CLINICAL AND ADMINISTRATIVE STAFF REQUIRED TO WORK WITH HEALTH RECORDS Supporting INFORMATION GOVERNANCE POLICIES AND Documents and PROCEDURES References: Review Date: MARCH 2013 Joint Lead DIRECTOR OF ICT/MEDICAL DIRECTOR Executives: Author/Lead Manager: Further Guidance/ Information: RECORDS MANAGER on behalf of HEALTH RECORDS MANAGEMENT GROUP RECORDS MANAGER EXT: 66838, ASST HEALTH RECORDS MANAGER EXT: 55044, 59392, MARCH

2 CONTENTS PARAGRAPH TITLE PAGE 1 Policy Statement 4 2 Policy Governance Legal Obligation and Good Practice Documentation and Professional Accountability Good Record Keeping ensures that: Health Record Keeping Standards Health Records Management Group (HRMG) 7 4 Audit and Quality Monitoring Staff Training 9 6 Implementation and Monitoring Plans 9 7 Review 10 8 Relevant Legislation and Guidance 10 9 Relevant Trust Policies and Procedures Further Information Equality and Diversity Statement 10 Appendix 1 Equality Impact Assessment Report Appendix 2 Staff Record of Having Read the Policy Appendix 3 Procedure for Health Record Keeping Procedure - Appendix A Clinical Nurse Specialist Documentation Procedure - Appendix B Guidelines for Developing Documentation at NUH Procedure - Appendix C Audit Templates (PDF Files) MARCH

3 1. POLICY STATEMENT This policy forms part of the total approach to improving the quality of record keeping at Nottingham University Hospitals NHS Trust and compliments a wide range of Trust policies and procedures and national guidance including: Reference: Information for Health The Health Quality Service Accreditation Standards Information Governance Toolkit Requirements The Royal College of Physicians, Generic Record keeping Standards (2008) Standards for Better Health NHS Litigation Authority Risk Management Standards The Research Governance Framework The EU Directive 2001/20/EC - implementation of good clinical practice in the conduct of clinical trials on medicinal products for human use ICH harmonised tripartite guideline for good clinical practice 1996 The Royal College of Physicians/The Audit Commission Improving clinical records and clinical coding together (2009) The policy intends to provide clear guidance for all clinical staff on the standards of professional practice relating to record keeping. It is concerned in the main with the content and quality of health records and is an adjunct to the Trust s Health Records Management Policy and Strategy, which deals with the management of health records. This policy applies to all health records. record which: A 'health record' means any a) Consists of information relating to the physical or mental health or condition of an individual and MARCH

4 b) Has been made by or on behalf of a health professional in connection with the care of that individual 2. POLICY 2.1 Governance The 1999 NHSE Guidance on Clinical Governance identifies high quality recordkeeping as one of the components of Clinical Governance and we must ensure that health records made by staff within the Trust are of consistent quality. This will be achieved by: Establishing and maintaining consistent standards of record keeping throughout the Trust Ensure all clinical records comply with professional standards and those of accreditation bodies Ensure that record keeping meet legal obligations Ensure that the requirement under Clinical Governance for effective monitoring of clinical care and high quality systems for record keeping are met Support evidence based clinical practice and improvements in clinical effectiveness Ensure that the requirements under the Research Governance Framework for effective monitoring of research related record keeping are met Ensure that the statutory requirements or the EU Directive 2001/20/EC are adhered to regarding good clinical practice in record keeping for clinical trials 2.2 Legal Obligation And Good Practice Although the primary purpose of health records is to facilitate continuity of care and to act as a tool of communication, good records allow a clear picture of events to be obtained which is vital for legal or evidential reasons. Records must be objective and worthy of independent scrutiny in the event of an investigation their content can be critical. The approach to record keeping which courts of law adopt tends to be that if it is not recorded, it has not been done 1. 1 Guidelines for Records and Record keeping. Nursing & Midwifery Council. MARCH

5 2.3 Documentation And Professional Accountability All healthcare practitioners and staff involved in clinical care or undertaking research are professionally accountable for keeping clear, legible, accurate and contemporaneous clinical records which record all the relevant clinical findings, any decisions made, information given to patients and any drugs or other treatment prescribed. All clinicians have both a professional and a legal duty of care to patients. All professional organisations will expect that you maintain and deliver high quality standards of care and this includes record keeping. Record keeping standards are an indication of your professional practice. A health record should inform any clinician who has a responsibility for the patient of all the key features which might influence the treatment proposed. It should also provide a contemporaneous and clear record of the patient's treatment and related features. A good record speaks volumes about the care a patient has received, and has a vital role in minimising clinical risk. Good record keeping safeguards both patients and professionals from unsafe practice through the misrecording or misunderstanding of health record information. General principals of the Trust s Health Records Management Strategy must also be pursued in every area. 2.4 Good Record Keeping ensures that: Staff can work with maximum efficiency without having to waste time searching for information Any record entry or alteration can be traced back to a named individual at a given date/time Those that caring for the patient can see what has been done, and still needs to be done and the reasons for this Any decisions made can be justified or reconsidered at a later date if the situation changes 2.5 Health Record Keeping Standards The Trust audits against standards and requirements set by national, professional and accreditation bodies. These include Clinical Risk Management Standards set by the NHS Litigation Authority. MARCH

6 The Trust recognises that there are two main areas in developing standards for clinical records and these are in generic and in professional quality. Generic quality is concerned with the basic content and structure of the record Professional quality relates to the value of the record as an effective communication tool Existing national standards from which the Trust s own audited standards are drawn, principally relate to generic quality. However, in the future, and with national direction where work in developing professional standards in communication are continuing, the Trust will consider the incorporation of further professional quality standards. 2.6 The Health Records Management Group (HRMG) The Trust has a Health Records Management Group. The HRMG reports to the Trust Board via the Information Governance Committee. Members of the group include a range of personnel involved in creating and maintaining the health record. The group's objectives are: To promote a culture of excellence in record keeping To improve and monitor the quality of record keeping and the design of the health record To monitor and respond to local, regional and national policies and standards relevant to the health record To ensure that the work of the Health Records Management Group integrates with the Trust s Clinical Governance agenda To monitor adherence to the Health Records Keeping Policy 2.7 Audit and Quality Monitoring As record keeping plays such a vital part in good clinical practice, the Trust monitors performance in generic standards in health record keeping through the Clinical Audit Process. Audit will be patient focused and will involve the records of all professionals who provided treatment or care for selected patients. MARCH

7 The Clinical, Quality, Risk & Safety Team will develop generic minimum data set templates based on the latest national and professional guidance and co-ordinate the audit across the Trust. See Appendix C. healthcare records. These templates form the basis of ALL audits of The audit of health record keeping will be included in the Annual Clinical Audit Programme. It will be undertaken at speciality level to ensure local ownership of the outcomes of the audit. However, it is the responsibility of the Clinical Directors to ensure that the audit is undertaken in line with the Clinical Effectiveness and Audit Policy and associated procedures. The Health Records Management Group will receive quarterly status reports on all health record keeping audits and will report to the Clinical Effectiveness Committee any concerns. The Clinical Effectiveness Committee will have overall responsibility for ensuring that the audit of health record keeping is undertaken and reported in line with the Policy on Clinical Audit and Service Evaluation and associated procedures. NUH paper based health records are currently used as the source of retrospective audit data. Electronic records are supported by audit trails, which record details of all additions, changes, deletions and viewings. Typically the audit trail will include information on: WHO identification of the person creating, changing or viewing the record WHAT details of the data entry or what was viewed; WHEN date and time of the data entry or viewing; and WHERE the location where the data entry or viewing occurred. The British Standards Institute (BSI) have issued a code of practice on the legal admissibility of electronic records which the Trust aims to comply with to maximise the evidential weight of electronic records (DISC PD 0008:1999, Code of Practice for Legal Admissibility and Evidential Weight of Information Stored Electronically, ISBN ). Compliance with the Code does not guarantee legal admissibility but it does define best practice. MARCH

8 The Connecting for Health Information Governance Toolkit currently requires the Trust to participate in continuous self-assessment of it s Information Governance arrangements, including those for the management of electronic records to ensure it meets expected performance levels in such areas as electronic system and process security and integrity. The Trust s electronic record keeping systems are ISO: 9000 compliant. Advice and guidance specific to audit trails for electronic records is due to be issued by the Department of Health. In the meantime, NHS organisations have been advised to retain all audit trails until further notice. Current audit in relation to electronic health records relates to compliance monitoring of records management technologies and their proper implementation and secure use. The Trust does not at present audit the professional quality of clinical record keeping within the electronic record environment, but aims to update it s procedures to do so once specific national standards are developed and promulgated. The NHSLA standards for accreditation will be used by the Trust Boards as key indicators for health records. 3. STAFF TRAINING 3.1 The policy has been produced to assist healthcare professionals and researchers to keep effective records. Managers in all areas where clinical records are created and used must ensure that staff are adequately trained, aware of, and work within the Trust s policy and procedural requirements. 3.2 The Trusts Training Needs Analysis document will address all training requirements including those for Clinical Record Keeping for healthcare professionals. 4. IMPLEMENTATION AND MONITORING PLANS The policy, endorsed by the Health Records Management Group, clearly sets out auditable requirements to: Measure compliance Support ongoing development and improvement in record content Monitoring adherence to this policy is the responsibility of the Health Records Management Group in partnership with Directorate Governance Committees. MARCH

9 5. REVIEW The Policy is due for review in March RELEVANT LEGISLATION AND GUIDANCE Records Management : NHS Code of Practice (DoH 2006) NHSLA Risk Management Standards The Health Care Commission. Standards for Better Health. Connecting for Health, IG Toolkit Standards The General Medical Council, Generic Medical Record keeping Standards (2008) ICH harmonised tripartite guideline for good clinical practice MRC ethics series good research practice Department of Health-Research Governance Framework Improving clinical records and clinical coding together (Royal College of Physicians/The Audit Commission 2009) A Clinician s Guide to Records Standards (Academy of Medical Royal Colleges/NHS Connecting for Health 2008) 7. RELEVANT TRUST POLICIES AND PROCEDURES 7.1 This policy should be read in conjunction with a number of Clinical Policies with specific record keeping requirements and with Information Governance Policies and Procedures. These can be viewed on the Policies and Policies Homepage on the Intranet: px 7.2 This Policy is supported by a Health Records Management Policy and Strategy which set out how records management systems will be delivered and a Clinical Audit and Service Evaluation Policy and associated procedures. 8. FURTHER INFORMATION Records Manager Ext: 66838,63975 Asst Health Records Manager Ext: 55044, 59301, MARCH

10 9. EQUALITY AND DIVERSITY STATEMENT All patients, employees and members of the public should be treated fairly, and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment. All Trust polices and Trust wide procedures must comply with the relevant legislation (non exhaustive list) where applicable: Equal Pay Act (1970 and amended 1983) Sex Discrimination Act (1975 amended 1986) Race Relations (Amendment) Act 2000 Disability Discrimination Act (1995) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act 1999 Code of Practice on Age Diversity in Employment (1999) Part Time Workers - Prevention of Less Favourable Treatment Regulations (2000) Civil Partnership Act 2004 Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001) Employment Equality (Sexual Orientation) Regulations 2003 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Age) Regulations 2006 Equality Act (Sexual Orientation) Regulations EQUALITY IMPACT ASSESSMENT STATEMENT NUH is committed to ensuring that none of its policies, procedures, services, projects or functions discriminate unlawfully. In order to ensure this commitment all policies, procedures, services, projects or functions will undergo an Equality Impact Assessment. Reviews of Equality Impact Assessments will be conducted inline with the review of the policy, procedure, service, project or function MARCH

11 11. ENVIRONMENTAL IMPACT ASSESSMENT Following the initial screening of this policy, a full impact assessment is not required at present as the policy does not create an environmental impact. MARCH

12 APPENDIX 1 Equality Impact Assessment Report Outline Remember that your EIA report should demonstrate what you do (or will do) to make sure that your service/policy is accessible to different people and communities, not just that it can, in theory, be used by anyone. 1. Name of Policy or Service Health Record Keeping Policy 2. Responsible Manager Deborah Coombs, Records Manager 3. Name of Person Completing Assessment Deborah Coombs Records Manager 4. Date EIA Completed 23 December Description and Aims of Policy/Service (including relevance to equalities) The policy details professional accountability and expected quality standards for clinical records and clinical documentation created by NUH staff. 6. Brief Summary of Research and Relevant Data See Policy 7. Methods and Outcome of Consultation HEALTH RECORDS MANAGEMENT GROUP MARCH

13 8. Results of Initial Screening or Full Equality Impact Assessment: Equality Group Age Gender Race Sexual Orientation Religion or belief Disability Dignity and Human Rights Working Patterns Social Deprivation Assessment of Impact No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified No Impact Identified 9. Decisions and/or Recommendations (including supporting rationale) Following the initial screening of this policy, a full impact assessment is not required at present as the policy relates to record keeping. 10. Equality Action Plan (if required) N/A 11. Monitoring and Review Arrangements (including date of next full review) It is recommended that this policy is reviewed inline with the current guidelines of NUH, unless there is a change in relevant legislation in which case, the policy should be reviewed within 6 months of new legislation and changes made accordingly. MARCH

14 APPENDIX 2 EMPLOYEE RECORD OF HAVING READ THE POLICY Title of Policy/Procedure: Health Record keeping Policy (and Procedures) I have read and understand the principles contained in the named policy. PRINT FULL NAME SIGNATURE DATE MARCH

15 APPENDIX 3 PROCEDURE FOR HEALTH RECORD KEEPING MARCH

16 PROCEDURE FOR HEALTH RECORD KEEPING 1 Who may document in the health record? 12 2 Linking each entry to the patient 12 3 Date and time on entries 12 4 Timeliness of entries 12 5 Pre-dating and back-dating 12 6 Authentication of entries and methods of authentication Entries by students and other unqualified staff 13 8 Signature Bank 13 9 Use of rubber stamps Specificity, Objectivity and Completeness Use of Abbreviations Legibility Continuous Entries Appropriateness of entries Children and Young People Document informed consent Notifications and communications Guidelines for handling corrections, errors, omissions and other documentation problems The patient and Subject Access Rights (The Data Protection Act 1998) Patient amendments to their health record Health record documentation and the Human Rights Act Private consultations and treatment Incidents Legal Forms Complaints files Documenting Care, Patient Held Records and Clinical Nurse Specialist Documentation Folders and filing of documentation Use of old type folders Structured document filing Health Record Forms/Stationery control process Patient Front Sheets Importance as a summary of information Clinical Trials Electronic Appendix B1 Clinical Nurse Specialist Documentation MARCH

17 Procedure For Health Record keeping 1. Who May Document In The Health Record? Entries may be made by any Trust employee who is directly involved in patient management. This includes staff who are employed by another organisation but who provide contracted services e.g. Speech and Language Therapy. 2. Linking Each Entry To The Patient and the most Senior Healthcare Professional 2.1 Every separate page in a paper based health record must be identifiable to the patient by name, hospital number and location in the hospital. 2.2 Every patient episode in the medical record should identify the Consultant responsible for the patient s care. If the Consultant or location changes this must also be recorded. 3. Date And Time On Entries Every entry made in the health record must record the date of the entry. Time of entries must be recorded for in-patient records (24-hour clock). For contemporaneous intrapartum record-keeping by midwives it is acceptable for the date to appear once per page. 4. Timeliness Of Entries Entries must be made as soon as possible after an event or observation is made and identify factors which jeopardise standards of care or place the patient or client at risk. An entry should never be made in advance (unless it is a plan). If it is necessary to summarise events that occurred over a period of time (such as a shift), the notation should indicate the actual time the entry was made with the narrative documentation. All entries should demonstrate a clear chronology of events. 5. Pre-dating And Back-dating Entries must never be pre-dated or back-dated and must always be dated for the time that the entry is made (see guidelines for handling corrections, errors, omissions and other documentation problems Section 16). MARCH

18 6. Authentication Of Entries And Methods Of Authentication Every entry in the health record must be authenticated (signed) by the author As a minimum the signature should include a signature, printed name and title/credential. If there are two people with the same surname making entries within the health record, they must both use their full signature/name. For contemporaneous intrapartum record-keeping by midwives it is acceptable for the printed name, title and credentials to appear once per page. If initials only are used there must be corresponding full identification of the initials on the same form or a signature legend within the record. Initials must never be used where a signature is required by law e.g. legal forms 7. Entries By Students And Other Unqualified Staff When it is appropriate for a member of staff to check a student s or another member of staff's entries, they should ensure that they are of an appropriate standard and countersign. 8. Signature Bank A signature bank for medical staff will be maintained within the Pharmacy Department. Upon appointment, medical staff are required to provide the Department of Human Resources with a specimen signature which is then registered with the Pharmacy Department. Various local signature banks are also maintained e.g. Physiotherapy and some wards. In addition to this, registers of Nurse prescribers and staff authorised to order controlled drugs are maintained. 9. Use Of Rubber Stamps The use of rubber stamps is permitted, but must always be accompanied by the initials and designation of the member of medical staff concerned. The stamp must only be used by the owner. 10. Specificity, Objectivity And Completeness When writing entries always use language that is specific rather than vague or generalised MARCH

19 Document all facts and pertinent information related to an event, or course of treatment. Always include the condition of the patient, their response to care and any deviation from standard treatment (including the reason for it). Make sure the entry is complete and contains all significant information. If the original entry is incomplete, follow the guidelines for handling corrections, errors or omissions 11. Use Of Abbreviations Use of abbreviations should be minimised and the risks associated with the use of abbreviations recognised. Some Allied Health Professionals maintain a local list of approved abbreviations. 12. Legibility All entries in the health record must be legible. Illegible documentation can put the patient at risk. All documentation must be readable to ensure continuity of care and give an account of each episode of care. You must use a dark pen so that if necessary, photocopies can be taken for legal purposes. 13. Continuous Entries Document entries in the next available space - do not skip lines or leave blanks. There should be a continuous flow of information without gaps or extra space between documentation. If you leave a large space/page accidentally, put a line through it. When you get to the end of a page and move on to a new piece of paper write 'continued'. 14. Appropriateness Of Entries Healthcare practitioners must use their professional judgement to decide what is relevant and what should be recorded. All entries from individual professions should conform to individual codes of professional practice. The health record should only contain documentation that is relevant to the direct care of the patient. Records should be free from statements that blame, accuse, or compromise other professionals, the patient or his/her family. The health record should not record opinions on issues that are not related to clinical issues or clinical opinion. MARCH

20 Items that may pose a health and safety risk or potentially infected material must not be placed within health records (e.g. CLO tests or foreign bodies removed from patients). If it is necessary to keep such an item it should be photographed and the photograph inserted in the record, or if necessary arrangements should be made for the item to be kept by Pathology. 15. Children And Young People In addition to this guidance where children are thought to be at risk of significant harm (in need of protection) guidance for documentation is set out in the recommendations of the Laming Inquiry 2 The report recommends that front line staff who regularly come into contact with families with children must ensure that in each new contact, basic information about the child is recorded. This must include the child s name, address, age, the child s school if the child is of school age and the name of the primary carer When a child is admitted to a hospital and deliberate harm is suspected, the nursing care plan must take full account of this diagnosis. All further discussions in respect of medical opinion, observations, nursing and medical handovers, including telephone conversations must be documented. Doctors must make comprehensive and contemporaneous notes of the concerns. If they are unable to make their own notes, they must be clear about what they wish to have recorded on their behalf. Where clinical staff are working in circumstances in which health records are not available to them, a record of all discussions must be entered in the health records at the earliest opportunity so that this becomes part of the child s permanent health record Decisions to share information with other agencies involved in the care of the child must be recorded in the health records, specifically what information was shared with whom and when and whether or not consent to that disclosure was obtained. If consent is obtained in writing then a copy must be filed in the record Decisions not to share information must also be recorded 2 The Victoria Climbie Enquiry. Lord Lamming. Presented to Parliament by the Secretary of State for Health and the Secretary of State for the Home Department by Command of Her Majesty. January MARCH

21 16. Document Informed Consent Informed consent must be carefully documented where applicable using the appropriate procedures and documentation. Specific guidance is contained within the Consent to Examination and Treatment Policy. 17. Notification And Communications If notification or communication to the patient s GP or family is required, or a discussion with the patient s family occurs regarding the patient s care it should be recorded. Where written communication occurs a copy must be filed in the Unit health record. 18. Guidelines For Handling Corrections, Errors, Omissions, And Other Documentation Problems There will be times when problems or mistakes occur and changes or clarifications to documentation will be necessary. Proper procedures must be followed in handling these situations Error Correction Procedure Draw a single line through the entry (thin pen line) Date, time and sign the entry Document the correct information Always make sure that the inaccurate information is still legible. Do not obliterate or otherwise delete the original entry by blacking out with marker, using correction fluid or writing over it. For errors or omissions on electronic systems contact the ICT Helpdesk 18.2 Handling Omissions In Documentation At times it may be necessary to make an entry that is late (out of sequence) or provide additional documentation to supplement or clarify entries previously written. When a pertinent entry has been missed, requires further clarification or not written in a timely manner, an appropriate entry should be used to record the information within the health record. MARCH

22 19. The Patient And Subject Access Rights (The Data Protection Act 1998) The Data Protection Act 1998 permits patients, on making an adequate written request, to be supplied with a permanent copy of any information held on computer about them, and/or to be supplied with permanent copies of any written records held. The Trust is obliged to be entirely open and subject to certain exemptions to provide patients with all of the information that it holds for them. In order to do this for written records, it is vital to ensure that all of our clinical information is traceable and kept within the patient s unit health record or other formally registered file series e.g. ED records, GU Medicine etc. The Data Protection Act applies to all clinical records held by the Trust. This includes those originating from private practice but held within the Trust libraries. NB Trust s notification does not cover private practice records. Photographs and film collections assembled by medical and other staff as part of their work within the Trust are property of the Trust and subject to Trust Policy. The Data Protection Act 1998 on registration of records, and restriction of disclosure, relates to photographs of identifiable individuals as well as to other personal records. Applications for Subject Access are centrally managed and processed by Patient Records Services at the QMC Campus in accordance within the provisions of the Act. 20. Patient Amendments To Their Health Record A patient can apply for inaccuracies in the record to be corrected. The health professional should either make the necessary correction or a note can be made in the relevant part of the record of the matters alleged to be inaccurate. Care must be made not to simply obliterate information that may have significance for the future care and treatment of the patient or for litigation purposes See section 18. Consideration should also be given as to whether it is appropriate to note any associated records. If the health professional does not agree to the patient s claim that their record is inaccurate and refuses to make such alterations, then the patient should be asked to provide a written statement detailing what they consider to be inaccurate and why (if they have not already done so) and a copy of that statement must be filed against that entry in the MARCH

23 case notes. Helpful guidance is contained within the linked document published by the National Information Governance Board for Health and Social Care Health Record Documentation And The Human Rights Act The Human Rights Act (HRA) came into effect in English Law on the 2 nd October The Act reinforces the need for good ethical, moral and legal practice in the delivery of quality services including healthcare. The principles of the HRA form part of our ongoing review of practice, policy and procedure, in particular: Transparency in decision-making Awareness of the rights of patients Clarity in communication with patients Good policies, particularly in difficult areas In terms of health records, it is important that healthcare professionals adhere to the Health Records Keeping Policy and document clearly the reasons for their decisions and who has been involved in the decisionmaking process. Areas that need particular care affecting health records may be: Recording Do Not Resuscitate (DNR) decisions Living Wills Decisions to withdraw or withhold treatment 22. Private Consultations And Treatment It is sensible from an administrative and from a Health & Safety perspective for records of private consultations and treatment performed on Trust premises and for NHS patient records to be held within a single record. Records are then managed appropriately in accordance with the Data Protection Act and other statutory requirements. The risk of Clinical Governance issues arising from cases where patients have been treated privately on Trust premises, but subsequently treated as an NHS patient will be minimised if private records are contained within the Trust health record. MARCH

24 If records of private treatment are made which are then kept within a private system, these are the responsibility of the individual who made them and must not be made on Trust letter headed paper or kept on a Trust computer. If Trust health records are required for private consultations and treatment at private healthcare premises, the Trust will make a small administrative charge for providing the record. 23. Incidents Incident reporting is a fundamental part of our clinical governance arrangements. When a patient safety incident occurs, the facts of the occurrence must be documented within the health record and a separate Trust Incident Report Form completed. Incident Report Forms are part of the Incident Reporting procedures and are generated as part of the Governance arrangements within the Trust. Incident Report Forms must not be filed within a patient's health record. However, it is acceptable to document in the records that an incident form has been completed. 24. Legal Forms Death certificates, cremation and post mortem forms must all be completed in accordance with Trust Policy and Procedures A full signature must always be used on a legal form 25. Complaints Files The Trust keeps patient complaints and associated complaints correspondence apart from a patient s clinical records in a separate Complaints File in a secure environment. Documentation associated with patient complaints must not be filed within patients' health records. This may be considered potentially prejudicial to a patient's future care and jeopardise confidentiality of patients and staff. The complaints documentation does not form part of the patient s health record and it is not usually included when requests for health records are made under the Data Protection Act However, they are still classed as personal information and are accessible by the person concerned should they request it. MARCH

25 The complaints file is confidential and only those who need to access them will be given permission 26. Documenting Care, Patient Held Records And Clinical Nurse Specialist Documentation Whenever a patient is seen by a medical professional, in general (with any exceptions to the Unit system in accordance with the Trust s Health Records Management Strategy), an entry must be made in the appropriate Trust health record for that campus, to document consultation and treatment. This entry is in addition to any entry in a patient held record. This guarantees that reliable information is available to the Trust in the event of a complaint or another investigation. Patient held records are used in some areas, notably for Maternity Care. The purpose of patient held records is to allow the immediate sharing of patient's medical information and to inform and involve the patient/carer. However, this record is not intended to replace the Unit health record and there are risks associated with completely relying upon the integrity of the information within a patient held record as there is no guarantee of the availability of the record or the authenticity of entries or alterations. For detailed guidance on Clinical Nurse Specialist Documentation see Appendix A. 27. Folders And Filing Of Documentation The health record folder and accompanying stationery is intended to support effective healthcare through the effective organisation of documentation and accordance with the standards set out by professional and accreditation organisations. The folder design adopted at NUH represent the results of consultation with a variety of clinicians and a wide range of users, reflect best practice elsewhere in the NHS and address the specific requirement of accreditation bodies, most notably the Risk Management Standards of the NHSLA. The Health Records Management Group addresses all issues affecting the health records folder and documentation design. 28. Use Of Old Type Records Folders MARCH

26 For logistical and economic reasons it is necessary to continue to use existing old format records alongside records of newer types until they become non-current. 29. Structured Document Filing In order to meet the specific NHSLA Risk Management Standards, folders do not have a back filing pocket to minimise the risk of misfiling or lost documents. This requires all standard stationery documents used within the Trust to be manufactured with two holes drilled The filing policy and responsibilities for filing patient documentation are clearly printed on health record folders. All staff are required to use the established document filing systems and to file all documents onto the spines within folders. Documents are stored in a logical indexed order behind named dividers to make them easily accessible. All areas using health records are responsible for supplying and using stationery, including health record front-sheets and ID labels appropriately to facilitate good record keeping practices. Health records leaving wards, Secretaries offices etc, must not contain loose documentation and it is every user s responsibility to ensure that items are filed appropriately BEFORE returning records to the library or passing on to other users. Individual documents must never be removed from the health records folder or separated from a records entirety. 30. Health Record Forms/Stationery Control Process There is a formal process for reviewing, approving or revising existing health records forms/stationery. New stationery forms to be used within health records must be submitted to the Health Record Management Group (HRMG) for approval prior to incorporation into the health record. Pilot forms must also be submitted to the group with a start and stop date specified. Request for approval/change of existing forms must include rationale for change. The Nursing Documentation Group must approve requests for new or amended nursing documentation. These authorities will from time to time identify forms which should be deleted and advise the Supplies Department that the form should no longer be supplied for use. MARCH

27 New forms will not be assigned a Supplies code without prior approval of the HRMG or appropriate Trust Nursing authority. Forms must be titled and indexed. A master copy of each printed form is retained by the Supplies Department. Design and content of forms/stationery must facilitate good record keeping practices. New forms will be reviewed for content, potential duplication of information already being documented, and inclusion of essential identification information: patient s name, hospital number, page numbers (page x of y) and revision date if applicable. Each document must be two hole drilled and devised to allow space for a patient ID sticker or to write the patient s full name and unit number onto every page. Forms must be no larger than A4 size, contain a margin for recording the date and time of entries (the time is only required for in-patient stationery) and have faint lines to aid legibility, where this is at all practical. Machine produced tape results, e.g. CTG s, ECG's, and medical photographs must be securely filed in the envelopes provided for this purpose as a stock stationery item via the Supplies Department. At the City Hospital Campus, manila envelopes are currently used for this purpose and must be filed within the health record with a patient ID label on the envelope. Forms used within health records where possible that are intended for long term use (i.e. not a pilot or trial form) must be printed via the Supplies Department. Photocopies should only be used for pilot or trial forms. This is also the most cost-effective way of production. The Nursing and Midwifery Documentation Group have produced a checklist staff developing health record documentation for use within NUH. This forms Appendix D of this document. 31. Patient Front Sheet Importance Of A Summary Of Information The health record front-sheet printed from PAS contains an important summary of all demographic patient data held. At the QMC Campus this includes important Clinical Alerts MARCH

28 Alerts must NOT be recorded in writing on the front cover of health record folders because recording alerts or other information in this way may unintentionally breach patient confidentiality Both campuses have a procedure for recording clinical alerts on PAS and HISS 32. Clinical Trials The Trust is required to keep the health records of all patients involved in clinical trials in accordance with the statutory requirement of the EU Directive 2001/20/EC. The Directive states that all clinical trials must be conducted according to Good Clinical Practice (GCP) guidelines. GCP states that all source data, including hospital records, must be retained for two years beyond any marketing authorisation, which in practice is a minimum of fifteen years. It is the responsibility of the lead investigator conducting the clinical trial to ensure that the health records of patients involved in such trials are clearly marked to ensure that the health records are retained for the appropriate period of time. The current method of identifying the health records of patients involved in clinical trials is to place a sticker on the outside cover of the health record. The sticker should clearly contain the date the health records will no longer be required for the statutory retention period. If a patient completes a clinical trial and is then entered into another trial, the sticker from the previous trial must be replaced with the new date (providing that the new date is not less than the previous date if this is the case the old sticker should remain valid). MARCH

29 CLINICAL NURSE SPECIALIST DOCUMENTATION APPENDIX A 1. Introduction The roles of Clinical Nurse Specialists (CNS) are extremely diverse. Whilst all work as independent practitioners to some degree, some have a remit for caring for patients with a specific medical diagnosis whilst others focus on particular patient problems or symptoms. However, no matter how a CNS works, it is essential that accurate and appropriate records are maintained. 2. Specialist-Held Patient Records Any record created, including, for example, logs of telephone conversations and subsequent action, may be required as evidence for complaints or legal purposes. Therefore, Patient Record Services must be aware of all records in existence for a patient and be able to locate them. Although it is preferable that all interventions are recorded directly in the patient record, it is acknowledged that this might not always be possible or desirable. Therefore, if any patient records are kept separate from the main record, this separate volume of the patient's record must be registered with the Patient Record Service. This volume will be an additional folder to the patient's registered file series and will be registered on the QMC Records Tracking system as 'Clinical Nurse Specialist notes' (New volumes can only be created by contacting the Patient Records Library on extension 42257) or noted at the City Hospital Campus on the HISS system. These specialist guidelines recognise the need for flexibility, whilst acknowledging the importance of keeping accurate records which reflect the care needs of individual patients. 3. General Principles For Health record keeping Records must be kept for each individual patient seen by a Clinical Nurse Specialist Records must be managed in accordance with the Trust s Health Records Management Strategy and Health Records Keeping Policy Records which have a direct influence on the care of an individual patient must be immediately accessible to the multi- MARCH

30 professional team caring for that patient (i.e. entries made in the patient s medical and/or nursing notes) Records must be made of telephone interactions with patients and their carers Records should reflect the guidance given from the Nursing and Midwifery Council s (NMC 2002) Guidelines for Records and Record keeping 4. Communication With Members Of The Multi-Professional Team Often, the CNS works as an independent practitioner. Therefore, it is essential that effective communication with the multi-professional team is maintained. This is normally achieved by making appropriate entries in the patient s medical or nursing notes. However, it may be necessary to follow up this written entry with a discussion with the relevant member(s) of the healthcare team, for example, Nurse in Charge, Allied Health Professional, Medical Team, Social Worker, District Nurse, GP. As already outlined above, all patient records must be accessible in the event that they are required for legal purposes or to comply with applications made under the Data Protection Act. Therefore, registration of records kept by the CNS is essential. In addition, it is important that staff maintaining records are able to use the Trust s casenote tracking system to record movement of casenotes in their possession. Training can be arranged via ICT Services on extension Suggestions for types of information which may be collated 5.1 Patient Details/Demography Name Date of Birth Hospital Number Address and Postcode Telephone Number Next of Kin Date of Admission Date of Referral Consultant General Practitioner District Nurse Length of CNS Consultation Source of Referral In-patient/out-patient Elective/Emergency Medical Team Ward/Clinic/Department Primary Care Team Person Making Referral Consultant Member of the Team Ward/Clinic/Department Nurse Professional Allied to Medicine MARCH

31 Other Specialist Nurse Self or Family Referral Reason(s) for Referral Uncontrolled Symptoms Specialist Advice Psychological/Spiritual Support Social Needs Management Medical Diagnostic Information Medical Diagnosis/Diagnoses Relevant Medical History Current Medication Relevant Tests and Investigation Results 5.2. Specialist Nurse Analysis Of Problem Consider developing categories pertinent to the specialism to assist with problem classification, for example: Duration of problem Presenting features/symptoms physical, psychological, social, emotional Existing side effects Previously tried interventions plus efficacy 5.3. Specialist Nurse Interventions Consider developing categories to simplify process of recording interventions, for example: Advice to medical staff Recommendation to change prescription Initiation of a therapy Patient education Counselling Referral to other agencies 5.4. Other Information Dependent on the specialism other information may be pertinent, for example: Social history Familial traits Patient satisfaction MARCH

32 Dietary information Final outcomes 6. Computer Held Records More and more Clinical Nurse Specialists retain records on computer databases. These may already exist within a particular medical specialism (e.g. Diabetes, Haemostasis and Thrombosis) but may be available from external enterprises with an interest in the field. However, if such databases are used, care should be taken as ongoing support in managing the database may be minimal or non-existent. All databases must be registered with IT Data Protection & Security, ICT Directorate ext: In addition, databases must be protected by robust IT security systems funded by the Department involved. Compiling data on computer has added benefits as it may simplify the process of analysing information for the purposes of audit, annual reporting, development of business cases and so on. However, the Trust does not provide PAS links for non-core systems, so the CNS must be aware that it is their personal responsibility to ensure that all data entered is accurate. If using computer records, staff must abide by the Trust s ICT policies. 7. Referral Processes And Related Documentation Prior to establishing a referrals service, the CNS should identify which consultants patients are likely to need access to the service. An approach should be made to the consultants involved (this may be via the Clinical Director) to determine referral processes. Some consultants prefer a member of their medical team to make the referral, either by ringing directly or writing a referral in the medical notes. Others are happy for other healthcare professionals e.g. Nurse, Physiotherapist, to make direct referrals with or without discussion with the medical team. This varies considerably within and among Directorates dependent on the work of each Directorate and the nature of the nurse specialism. Referrals are commonly made by telephone and generally supported by a written referral. There are variations and exceptions to this dependent on the specialism involved. MARCH

33 Specialist services either utilise existing in-patient records as written referrals (e.g. patient s anti-coagulation cards) or develop their own referral documentation (e.g. Macmillan palliative care referral sheets). However, all referrals must be recorded in the patient s record. Where a written referral is inappropriate because it results in an unwanted delay in treatment, (e.g. acute pain), it may be appropriate to accept verbal referral. The individual specialism will determine what referral information is required. It may be appropriate for CNS s to set time limits in relation to the receipt of and response to referrals, for example: Any referrals made after hours cannot be seen that day; all referrals will be seen within 72 hours of receipt of referral In addition, to receiving referrals, some CNS s have the responsibility for identifying all patients who fall within their sphere of practice from admission records (e.g. respiratory CNS). MARCH