Electronically via Datix web safety alert to senior staff, all staff via the Trust website, Mandatory training Document Links

Transcription

1 Document Details Title Transfer of Clinical Care Policy incorporating SBAR tool Trust Ref No Local Ref (optional) Main points the document The main aim of this policy is to ensure that all directorates covers have adequate arrangements to ensure effective handover of patients between clinical teams providing care for patients. Who is the document This policy applies to all service directorates who have a aimed at? responsibility for direct patient care. Author Narinder Kular Nurse Consultant Community Paediatrics Approval process Approved by Steve Gregory Quality & Safety Committee (Committee/Director) Approval Date 08/09/2014 Initial Equality Impact Yes Screening Full Equality Impact No Assessment Lead Director Steve Gregory Category Clinical Sub Category All Clinical Review date September 2017 Distribution Who the policy will be All Staff distributed to Method Required by CQC Required by NHSLA Electronically via Datix web safety alert to senior staff, all staff via the Trust website, Mandatory training Document Links This is a mandatory risk management policy for the NHSLA Risk Management Standards accreditation Other Amendments History No Date Amendment New Policy Draft Copy and face to face discussions with individual stakeholders Final Amended after clinical policies V Reviewed up dated Clinical Policies incorporate SBAR tool V3 5

2 2 Shropshire Community Health Index 1. Introduction Purpose Definitions Duties Chief Executive Director of Nursing & Medical Director Service Managers All Clinical Staff Guidance on Clinical Transfers of Care Handover requirements between all care settings, to include both giving and receiving of information How handover is recorded SBAR Communication Tool What should an SBAR communication convey? Emergency and Out of Hours Transfer Single Point of Referral What if things go Wrong Dissemination and Implementation Consultation Monitoring Compliance References Associated Documents Appendix 1 Transfer of Care Table Service Directories Appendix 2 - Form 1a Clinical Handover Appendix 2 - Form 1b: SCHT SBAR Handover Record Appendix 3 - Special Patient Notes... Error! Bookmark not defined. Appendix 4 Single Point of Referral Service Leaflet Transfer of Clinical Care Policy Version V3 Review Date: September 2017

3 3 Shropshire Community Health 1. Introduction Handover of care.when carried out improperly can be a major contributory factor to subsequent error and harm to patients. This is always been so, but its importance is escalating with the requirement for shorter hours for doctors and an increase in shift patterns of working. Professor Sir John Lilleyman Medical Director National Patient Safety Agency (2004) This policy has been developed to ensure that Shropshire Community Health Trust (SCHT) has in place a systematic approach for the clinical transfer of care of patients from one clinical team to another at shift change or to achieve the efficient transfer of patient from one care setting to another. Handover involves both the giving and receiving of information and is a two way communication process. Individuals and organisations have a shared responsibility to ensure that effective communication lies at the very heart of good patient care. 2. Purpose This policy applies to all clinical staff working within SCHT Trust within all Adult and Children s services. This policy refers to clinical handover of patients and transfers to, from and between all the following Trust services: Community hospitals wards Community Inter-disciplinary teams & teams (Children Adolescent Mental Heath (CAMHS), Prison Healthcare, Preventative services, Diagnostics, access to assessment, rehabilitation & treatment (DAART), Shropshire Enablement Team, Substance Misuse, Advanced Primary Care, Diabetes Nursing service, Continence Service, Podiatry, Minor Injury Unit s, Therapy services) Children s Dental This policy should be applied in conjunction with the Clinical Discharge of Patients Policy. 3. Definitions AMHS AHPs APCS CAMHS Carer CCNT CMHT Adult Mental Health Service Allied Health Care Professionals Advanced Primary Care Service Children Adolescents Mental Health The term carer is used as the generic term for relatives/friends/neighbours that are providing unpaid care to the patient. They may not necessarily be living in the same household as the person they are caring for. Community Children s Nursing Team Community Mental Health Team Transfer of Clinical Care Policy Version V3 Review Date: September 2017

4 4 Shropshire Community Health CNR CSMT DAART DNAR EIP EG EWS GP Handover IDT MIUs Multi-Disciplinary Team (MDT) NHS NPSA OoH Out of Hours Handover Patient SaTH SBAR SCHT SPR Shropdoc Shrop Transfer of Care Community Neuro Rehabilitation Team [Previously known as SET Shropshire Enablement Team] Community Substance Misuse Team Diagnostic Assessment and Access to Referral and Treatment DO NOT ATTEMPT TO RESUSCITATE Early Intervention Programme Latin expression Exempli Gratia Early Warning Score General Practitioner Will involve minimal disturbance to the patient s activities of daily living. Does not prevent or hamper a return to their usual place of residence. Will not require a significant change in support offered to the patient or their carer in the community. Interdisciplinary Team Minor Injury Units The team of staff who contributes to the patient s care and/or discharge. EG Doctors, Nurses, AHP s, Health Care Assistants, Therapy assistants, Psychologist, Liaison Nurse., Social worker. National Health Service National Patient Safety Agency Out of Hours [time period 18:30pm-08:00am] A handover of information that takes place at night or weekends. [18:30-08:00 hours] The People receiving clinical services from the Trust are referred to as patients. Shrewsbury and Telford Hospitals S = Situation B = Background A = Assessment R = Recommendation SBAR is an easy to remember mechanism that can be used to frame communications or conversations. It is a structured way of communicating information that requires a response from receiver. Shropshire Community Health Trust Single Point of Referral GP OoH Provider in Shropshire & Telford Shropshire The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis NPSA Transfer of Clinical Care Policy Version V3 Review Date: September 2017

5 5 Shropshire Community Health 4. Duties 4.1 Chief Executive The Chief Executive has ultimate accountability for the strategic and operational management of the Trust, including ensuring there are effective and appropriate processes in place for the safe transfer of care for patients. 4.2 Director of Nursing & Medical Director The Director of Nursing & Medical Director have responsibility for ensuring that appropriate transfer of care processes for patients are in place and support patient safety at all times 4.3 Service Managers Service Managers are responsible for the day to day operational management of transfer of care processes for patients are in line with the policy and ensuring their teams are aware of the requirements of this policy 4.4 All Clinical Staff Clinical staff are key essential members in ensuring that safe and timely transfer of care takes place, and has the central role in coordinating the patient s handover in the clinical environment. All clinical staff are required to comply with this policy and to report any patient transfer of care related issues to their line manager and to complete a Datix incident report in line with the Trust s Incident reporting policy. 5. Guidance on Clinical Transfers of Care During a transfer, patients should be treated and cared for in such a way as to maintain: Patient safety Necessary treatment and care Contact with appropriate staff Dignity Respect of individual needs Contact with appropriate relatives and carers Confidentiality of information on a need to know basis Transfer of Clinical Care Policy Version V3 Review Date: September 2017

6 6 Shropshire Community Health 5.1 Handover requirements between all care settings, to include both giving and receiving of information Individual clinical areas will have their own requirements for handover dictated by the clinical work, the number of patients involved, their geographical distribution and the working patterns of the staff. It is therefore not possible to be descriptive about all transfer of care arrangements but all directorates should have predetermined arrangements detailing how clinical handover will occur. Service Directorates must have in place procedures for clinical transfer of care handovers between all groups of clinical staff within each department. Handover arrangements need to be recorded in order to ensure consistent practice and enable audit which handover processes can subsequently be audited. The record should cover each tier of staff amongst whom handover occurs and include details of: Who participates in handover When handover will be conducted What information is to be relayed When handover will occur How handover will be conducted What information is to be relayed o Minimum dataset for patients handed over o Criteria for highlighting specific issues How the information passed over at the handover of care is to be recorded for a permanent medico-legal record. Lastly, handover is of little value unless action is taken as a result: For example: - tasks should be prioritised - plans for further care are put into place - unstable patients are reviewed How handover is recorded Adequate documentation is an essential component of communication within the health care setting. The primary source of patient related information remains the patient s medical record folder. Whilst notes taken by staff at clinical handover meetings may be helpful to them during their forthcoming shift, it is of paramount importance that all critical information relating to the clinical care of patient appears in his or her medical notes. Handover is a two way process. Good handover practice is characterised by the team who are taking over the patient s care asking questions and having the opportunity to clarify points they are uncertain of. They should not be passive recipients of information. The SCHT transfer of care area s in each service directorate is area summarised in appendix 1 Transfer of Care table ; it is the duty of each clinical lead to advise on any changes that affect transfer of care to other services. The Clinical Transfer of Care Record Forms 1a and 1b as seen in appendix 2 should be used to record the handover of information which incorporates the SBAR tool; these forms can be adapted by each clinical lead to reflect the service delivery characteristics that may be pertinent to the service area transfer of care summary form. Transfer of Clinical Care Policy Version V3 Review Date: September 2017

7 7 Shropshire Community Health As such, SBAR can be used very effectively to escalate a clinical problem that requires immediate attention, or to facilitate efficient handover of patients between clinicians or clinical teams. The written documentation should be recorded using permanent ink and be readable when photocopied or scanned. It should be written clearly, legibly and in such a manner that they cannot be erased. Also, accurately dated, timed and signed (the signatory s name must be printed at the side of the first entry or be matched to an authorised signatory list). The signatory s designation / role must also be recorded (this can be alongside the signature or in a specific signature list held within the record). 5.3 SBAR Communication Tool Inadequate verbal or written communication is recognised as being the most common root cause of serious error - both clinically and organisationally. There are some fundamental barriers to communication across different disciplines and levels of staff. These include hierarchy, gender, ethnic background and differences in communication styles between disciplines and individuals. SBAR is an easy to remember mechanism that can be used to frame communications or conversations. It is a structured way of communicating information that requires a response from the receiver. As such SBAR can be used effectively to escalate a clinical problem that requires immediate attention (in conjunction with the EWS) protocol as deemed appropriate), or to facilitate efficient handover of patients between clinicians and clinical teams. 5.4 What should an SBAR communication convey? S: Situation o o o Identify yourself and the site / unit you are calling from Identify the patient by the name and the reason for your report Describe your concern: Firstly describe the specific situation about which you are calling, including patients name, consultant, patient location, resuscitation status and the vital signs B: Background Give the reason for the patient s admission o Explain significant medical history o Describe your concern: Give the patient s reason for admission (or presentation/referral in community care settings) o Overview of the patient s background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results (including infections and or colonization) and other relevant diagnostic results. Transfer of Clinical Care Policy Version V3 Review Date: September 2017

8 8 Shropshire Community Health For this, you need to have collected information from the patient s nursing / medical / progress notes. A: Assessment Vital signs Clinical impressions, concerns Not only should clinician s review findings from their objective assessment, these finding should also be consolidated with objective indicators, such as laboratory results. R: Recommendation o o o Explain what you need be specific about request and time frame Make suggestions Clarify expectations: Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation with the clinician? 5.5. Emergency and Out of Hours Transfer For urgent or Out of Hour clinical handover of information, staff should use the Special Patient Notes and for sharing information to achieve continuity of care/anticipatory care planning such as a specific management plan. Palliative care information Just in case box, DNAR etc refer to appendix 3. To transfer information that can be accessed by Shropdoc (GP OoH Provider Shropshire & Telford). This process will ensure that a consistent approach is in place in the OoH period. For urgent and OoH transfers, staff should use emergency transport, i.e. ring 999 to summon an ambulance. For urgent or Out of Hour clinical handover of information, staff should use the Flagging Form as seen in appendix 3, to transfer information about the patient onto the GP medical record, this information can then be accessed by Shropdoc (GP OoH Provider Shropshire). This process will ensure that a consistent approach is in place in the OoH period. For urgent and OoH transfers, staff should use emergency transport, i.e. ring 999 to summon an ambulance Single Point of Access Not all clinical services currently offer access via SPR in SCHT; for those services that do Single Point of Referral provides one contact number for all referrers and will continue to provide systematic access to community nursing services, refer to appendix 4 SPR Service Leaflet. This service is available to all Health Care Professionals. Patients who have end of life care needs, require catheter care or Warfarin Control also has access to SPR in order to provide an efficient response to their individual needs, and where care is being transferred from Children Nursing Service to Adult Nursing Teams. Transfer of Clinical Care Policy Version V3 Review Date: September 2017

9 9 Shropshire Community Health The SPR does not exclude clinical conversations. A clinician from the referring service should always be encouraged where possible to have a clinical conversation to the agency where the referral is being made to discuss any issues that may arise pertaining to patients care What To Do If Things Go Wrong If the process of a transfer of a patient goes wrong, the staff involved must ensure they complete the Trust incident form in line with the SCHT incident policy. 6. Dissemination and Implementation This policy will be disseminated and implemented by the following methods: Directors/Service Leads to disseminate within their areas Staff - via Team Brief process Published to the SCHT Website Training in the use of the SBAR tool can be accessed via the SBAR training Guide, which has been developed in conjunction with NHS Institute for Innovation and Improvement working closely with clinicians and other frontline staff in the NHS. SBAR resources include: DVD containing a series of filmed scenarios highlighting the difference of communicating with or without SBAR Series of filmed scenarios PowerPoint presentation introducing SBAR An SBAR e-learning module SBAR prompt cards and pads SBAR resources are downloads at 7. Consultation This policy is an updated version 3 and was circulated via: E- mail/ Face to face contact with: Dr Emily Peer Associate Medical Director General Practice Cath Molineux Nurse Consultant Primary Care Rachel Allen Head of Infection Prevention & Control Sharon Boyle Team Leader, Advanced Nurse Practitioner (CCNT) Alan Ferguson Records Manager and Quality Facilitator Kate Hidden Team Leader, Children s Occupational Therapy Gilly Scott Clinical Lead Nurse MIUs and DAARTs Peter Foord Corporate Risk Manager Transfer of Clinical Care Policy Version V3 Review Date: September 2017

10 10 Shropshire Community Health Elaine Edwards Nurse Director Shropshire Doctors Co-operative Ltd Sarah Watson Single Point of Referral and Home Delivery Service Manager Transfer of Clinical Care Policy Version V3 Review Date: September 2017

11 11 Shropshire Community Health 8. Monitoring Compliance This policy will be reviewed and updated every two years or as changes in best practice standards, guidance or legislation occurs. Compliance with this policy will be monitored according to the template below Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared The adoption of a standardised clinical transfer of care tool across SCHT localised to each clinical service area. Service Managers Patient records audit Annual The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Training in the use of Service SBAR for all registered Manager clinical staff working in community hospitals and community care teams within SCHT Safer Care SBAR Implementation & Training Guide Once every 3 years The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Transfer of Clinical Care Policy Version V2 Review Date: June 2017

12 12 Shropshire Community Health Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Out of hours Transfer of Care information process Service Manager Patient records audit Annual The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Information to be given to receiving healthcare professional Service Manager Patient records audit Annual The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Transfer of Clinical Care Policy Version V2 Review Date: June 2017

13 13 Shropshire Community Health Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared The review of audit data and the instigation of remedial action if deficits are identified. Service Manager Patient records audit Annual The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Ensure sufficient resources are in place to enable clinical handover, staff training in clinical handover, and on-going evaluation of the effectiveness of clinical handover to occur. Service Manager Patient records audit SBAR Tool Training for Staff Annual The audit report will be submitted to the Quality and Safety Group. The group is expected to read and interrogate the report to identify deficiencies in the system and act upon them Any changes to the process will be identified as part of the audit and allocated to a relevant person(s) within a specified timeframe Relevant clinical staff will be responsible for changes in the risk assessment. Lessons will be shared with all the relevant stakeholders. Transfer of Clinical Care Policy Version V2 Review Date: June 2017

14 14 Shropshire Community Health 9. References 1. NHS Institute for Innovation and Improvement Safer Care SBAR Implementation and Training Guide (2010) 2. Safe handover, sage patients: Guidance on the clinical handover for clinicians and managers. BMA Juniors Doctors Committee (2004) 3. Department of Health Expert Group (2000) Organisation with a memory. London: National Patient Safety Agency 4. Hoban V (2003) How to.handle a handover. The Nursing Times 99: Seven ways to no delays (2010) NHS Institute for Innovation and Improvement 6. High Impact Actions Ready to go: No delays NHS Institute for Innovation and Improvement (2010) 10. Associated Documents Clinical Record Keeping Policy Consent to Examination or Treatment Policy Clinical Discharge of Patients Policy Mental Capacity Act 2005 Policy Safeguarding Adult Guidelines Safeguarding Children & Young People Policy Risk Management Strategy and Policy Incident Reporting Code of Practice Early Warning Score Protocol for Community Hospitals and Prisons the Detect Deteriorating Patient Infection Prevention & Control Arrangements and Responsibilities Transfer of Clinical Care Policy Version V2 Review Date: June 2017

15 15 Shropshire Community Health Appendix 1 Transfer of Care Table Service Directories Area From(Service) To (Service) Area From(Service) To (Service) CAMHS & Psychology CAMHS & Psychology CAMHS & Psychology CAMHS & Psychology CAMHS & Psychology External Placing local authority CAMHS CAMHS CAMHS CAMHS Shrop / T&W Shropshire Private care provider Tier 4 unit AMHS EIP CAMHS elsewhere Child & Family Preventative Child & Family Preventative Child & Family Preventative Child & Family Preventative Child & Family Preventative Midwifery Out of Area Health Visiting Out of Area Out of Area Health Visiting Health Visiting School Nursing School Nursing Looked After Children CAMHS & Psychology CAMHS elsewhere CAMHS Shrop / T&W Child & Family Preventative Family Nurse Partnership Health Visiting Transfer of Clinical Care Policy Version V2 Review Date: June 2017

16 16 Shropshire Community Health Area From(Service) To (Service) Area From(Service) To (Service) IDT Nursing home Care Acute IDTs DAART OOH IDT Acute setting Care IDTs ShropDoc DAART Acute Care IDTs Tissue viability service DAART GP Care Inpatient, acute services such as SaTH or University Hospital North Staffs Shropshire Enablement Team Falls GP Care SET Community MH or Department of Psychological Therapies Out of hours nurses GP IDTs DAART Care SET Substance Misuse SET Social Care APCS- services Shropshire Secondary Care - diagnostics Transfer of Clinical Care Policy Version V2 Review Date: June 2017

17 17 Shropshire Community Health Area From(Service) To (Service) Area From(Service) To (Service) SET GP Care APCS services - Shropshire Back to GP- finished treatment APCS services Shropshire APCS from referrers Care APCS Shropshire Back to GPs not suitable for services e.g. warts etc APCS services Shropshire Secondary care from Triage Care APCS Shropshire particularly dermatology Secondary care- triage 2 week rule patients APCS services Shropshire Secondary care- further treatment Care SaTH hospital wards & departments Diabetes Nursing (DSN) Service Other Wheelchair if user moves into area Wheelchair & Posture Service Care North Staffordshire Hospital Trust Diabetes Nursing Service APCS services Shropshire APCS from referrers Care Podiatry & Foot Health all staff Referrals sent back to GP s as inappropriate referral made in first instance APCS services Shropshire Secondary care from Triage Care Podiatry & Foot Health - -all staff Secondary care Acute diabetic foot ulcer clinics Transfer of Clinical Care Policy Version V2 Review Date: June 2017

18 18 Shropshire Community Health Area From(Service) To (Service) Area From(Service) To (Service) APCS services Shropshire Secondary care- further treatment Care Podiatry & Foot Health Secondary care dermatology Children s & spec services Clients being released from prison CSMT Children s & Other drug service CSMT Children s & C.S.M.T Other drug services Care Community wards Out of county transfers Children s & C.S.M.T CMHT Care Community wards From SATH Children s & C.M.H.T CSMT Care Community wards From SATH Ward SaTH/Acute for diagnostics Care Community wards From SATH Service Delivery, Community Nursing and specialist nursing Care homes particularly nursing homes Care APCS services Telford & Wrekin APCS from referrers Transfer of Clinical Care Policy Version V2 Review Date: June 2017

19 19 Shropshire Community Health Area From(Service) To (Service) Area From(Service) To (Service) IDTs Social care I APCS services Telford & Wrekin Secondary care from Triage APCS services Telford & Wrekin (Dermatology) Secondary care- triage 2 week rule patients Care APCS services Telford & Wrekin Secondary Care - diagnostics Children s Medical and Therapy Child development centre School / nursery Care APCS services Telford & Wrekin Secondary care- further treatment Children s Medical &Therapy Service Consultant led out patient clinics Any service available Care APCS services Telford & Wrekin Back to GP- finished treatment Children s Medical and Therapy Community Paediatric(T&W Movement Centre RJAH Care MIU To A&E Children & Young families Directorate Children & Young families Directorate Children & Young families Directorate Acute Hospitals MIU Health Visitors/ School Nurses. Community Children s Nursing Team Community Children s Nursing Team Community Children s Nursing Team Children & Young families Directorate Care Children & Young families Directorate Self Referral SaTH wards GP/Shropdoc Community Children s Nursing Team Community Hospital wards Community Children s Nursing Team Transfer of Clinical Care Policy Version V2 Review Date: June 2017

20 20 Shropshire Community Health Area From(Service) To (Service) Area From(Service) To (Service) Children & Young families Directorate Children & Young families Directorate MIU Health Visitors/ School Nurses. Community Children s Nursing Team Community Children s Nursing Team Care Care APCS- services Shropshire Podiatry & Foot Health all staff Secondary Care - diagnostics Referral for shared care with district nurses SaTH wards Community Hospital wards Transfer of Clinical Care Policy Version V2 Review Date: June 2017

21 21 Shropshire Community Health Appendix 2 Form 1a Clinical Handover The SBAR tool originated from the US Navy and was adapted for use in healthcare by Dr M Leonard and colleagues from Kaiser Permanente, Colorado, USA S Situation: I am (nurse), (X) a nurse on ward (X) I am calling about (patient X) I am calling because I am concerned that.. (e.g. BP is low/high, pulse is XX temperature XX, Early Warning Score is XX) B Background: Patient (X) was admitted on (XX date) with (e.g. MI/chest infection) They have had (X operation / procedure/investigation) Patient (X) s condition has changed in the last (XX mins) Their last set of obs were (XX) Patient (X) s normal condition is (e.g. alert/drowsy/confused, pain A Assessment: I think the problem is (XXX) and I have. (e.g. given O 2 / analgesia, stopped the infusion) OR I am not sure what the problem is but patient (X) is deteriorating OR I don t know what s wrong but I am really worried R Recommendation: I need you to Come to see the patient in the next (XX mins) AND Is there anything I need to do in the meantime? (e.g. stop the fluid/repeat the obs) Ask receiver to repeat key information to ensure understanding Transfer of Clinical Care Policy Version V2 Review Date: June 2017

22 22 Shropshire Community Health Appendix 2 - Form 1b: SCHT SBAR Handover Record Patient Details Name: DOB: Address GP Details Name: Practice: NHS No: Fax Number: Situation Identify yourself the site/unit you are calling from Identify the patient by name and the reason for your report Describe your concern Firstly, describe the specific situation about which you are calling, including the patient s name, consultant, patient location, resuscitation status, and vital signs. Background Give the patient s reason for admission (Or presentation/referral in community care settings) Explain significant medical history Overview of the patient s background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. For this, you need to have collected information from the patient s medical notes. Assessment Vital signs Clinical impressions, concerns Recommendation Explain what you need be specific about request and time frame Make suggestions Clarify expectations Finally, what is you recommendation? That is, what would you like to happen by the end of the conversation with the clinician? Any order that is given on the phone needs to be repeated back to ensure accuracy Type of handover Verbal Face to face Telephone Fax Letter Handover given by (print name).designation Handover received by (print name) Designation Signature

23 23 Shropshire Community Health Appendix 3 Shropdoc Flagging Guidelines SPECIAL PATIENT NOTES Please complete the Patient Details and the notes and fax them back to us for a patient to be flagged on our computer system. The instructions will be kept for future reference for as long as the notes are valid. PATIENT DETAILS Male Female SURNAME D.O.B ADDRESS POSTCODE NHS No. FIRST NAME TEL. No. PATIENT NOTES Shropdoc operates a policy of good practice around information sharing. The sender of this form assumes responsibility for sharing this information in accordance with the provisions of the Data Protection Act 1998, Caldicott Principles and NHS Good Practice Guidelines around patient consent and confidentiality. If the form is sent electronically, it must be done from an nhs.net address. ONE of the following categories MUST be selected;: Child at Risk, Palliative Care, Addiction, Mental Health, Violent Risk / Risk to HCP, Basic Notes (other e.g. telehealth) DATE: CATEGORY: CLINICAL NOTE: Please review this note in: 1 week 1 Month 3 Months 6 Months (please circle.) Please remove this note in: 1 week 1 Month 3 Months 6 Months (please circle.) SIGNED: POSITION: The information contained in or attached to this document is intended only for the use of the individual or entity to which it is addressed. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are not authorised to and must not disclose, copy, distribute, or retain this message or any part of it. This document may contain confidential information.

24 Single Point of Referral Service Leaflet Appendix 4 Single Point of Referral How to make a Referral For all new community referrals and domiciliary phlebotomy requests call Single Point of Referral Referrer to identify service required An operator will take your referral What information will be required? Patient Details to include NHS number Referrer contact details Environment / Access issues to include key codes Hospital Admission details if applicable Reason for referral Already known to the community nursing service A Community Nursing authorisation for administration of medication Who can make a referral? Any Healthcare Professional Practice Admin Staff Nursing Home Staff Care Agencies Voluntary Patients with end of life / catheter issues If you would like to make a compliment or complaint about the service. Please contact: Shropshire Community Health NHS Trust Halesfield 6 Telford Shropshire TF7 4BF Telephone: Fax: Single Point of Referral A Guide for Health Care Professionals Back L- R: Julie, Sarah Watson Service Manager and Nicola Front L-R: Gill, Sophie, Lucy and Karen Single Point of Referral provides one contact number for all new referrals and will continue to provide systematic access to community nursing services. T: F: Operational Hours: M-F Sa-Su-BH s Out of Hours please contact Shropdoc

25 25 Shropshire Community Health What is Single Point of Referral? Single Point of Referral provides one contact number for all referrers and will continue to provide systematic access to community nursing services. Who can use this service? This service is available to all Health Care Professionals. Patients who have end of life care needs, require catheter care or Warfarin Control also have access to SPR in order to provide an efficient response to their individual needs Benefits Provides one number for access to services in the right place at the right time Provides a pro-active and holistic approach to care Provides a signposting service if required Referral information taken by administration staff, to include the co-ordination of additional information eg authorisation to prescribe medication and EMIS summaries Reduction in clinical time spent undertaking administrative tasks Urgent referrals signposted / passed to teams efficiently and appropriately Clinical support and guidance available at all times to support administration staff Reduction in duplication of paperwork for patients already known to service What services can I refer to through SPR? Community Nursing Teams Respiratory Nurses Domiciliary Phlebotomy Domiciliary Physiotherapy Therapy Teams URGENT End of life care. Syringe drivers. Blocked catheters. Deep Vein Thrombosis (DVT). IV Therapy, Exacerbation of LTC Acute Illness etc Examples of Clinical Priorities SEMI-URGENT Wound dressing (new, daily) Suture removal Non-acute Long-term conditions (LTC) Hospital discharges that need assessment within 24hrs. ROUTINE Ongoing monitoring of patients with a LTC. Ongoing preventative care/advice. Chronic disease management Planned ongoing care Routine injections eg B12, zoladex. Once referral has been received by a nurse the patient will be seen and assessed within 1-3 hours Once referral has been received the patient will be seen and assessed that day or within 24hrs depending on information given by referrer This will be determined on an individual patient basis guidance will be given by referrer.