PATIENT IDENTIFICATION POLICY
|
|
- Ellen Linette Randall
- 6 years ago
- Views:
Transcription
1 PATIENT IDENTIFICATION POLICY DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Effectiveness Committee Date ratified: 12 th January 2012 Name of originator/author: Clinical Policy Advisor Name of responsible Clinical Effectiveness Committee committee/individual: Date issued: 27 th January 2012 Review date: January 2015 Target Audience All staff in contact with patients/patient records
2 CONTENTS SECTION PAGE NO 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES Board of Directors Assistant Directors Clinical Leads/Matrons Clinical Staff Medical Secretaries/Health Records Admin Staff 4 5. PROCEDURE/IMPLEMENTATION Patient Identification Mental Capacity Consideration Identification Steps Wristbands Patient s who do not wear wristbands Photographs Community Services Safety Incidents 6. TRAINING IMPLICATIONS 8 7 MONITORING ARRANGEMENTS 9 8. EQUALITY IMPACT ASSESSMENT SCREENING Privacy, Dignity and Respect 9 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS REFERENCES APPENDICES 10 Appendix 1 Audit Form 11 Appendix 2- Flowchart for Patient Identification Process 12 Page 2 of 12
3 1. INTRODUCTION 1.1 The National Patient Safety Agency (NPSA) has recognised that patient misidentification is a widespread problem within healthcare organisations. Failure to correctly identify patients constitutes a significant risk to the organisation and poses a serious risk to patient safety. 1.2 Patient identification practice is intrinsically tied to verification practices. All health care providers must always verify that the person they are attending to is the one for whom the treatment is intended. 1.3 While the NPSA promotes the use of ID wristbands in Acute Hospital settings, their Safer Practice Notice 24 (2010) acknowledges that Mental Health In-patient services need not use patient wristbands, although if they are being used, they must comply with the NPSA standards. 1.4 In areas where wristbands are not worn the relevant Service Areas must have a photograph for validating a patient s identity. For those patients who are unable to provide their own details due to their current health or mental capacity a care plan must be written detailing the way of validating their identity. 1.5 In areas where wristbands are worn care must be taken when completing the information as significant consequences can occur if an error is made. The NPSA has issued guidance on the information required, which includes using the patients NHS Number. 2. PURPOSE The purpose of this policy is: To raise staff awareness of the importance of obtaining, recording and confirming the patient s identity at all times, both in hospital and community settings, and especially prior to any intervention or treatment, thus promoting patient safety. To provide direction to staff on a corporate and standardised approach to patient identification and the use of wristbands/photographs to promote patient safety. To promote compliance with the NPSA Guidelines on standardised wristbands. To enable the Trust to be compliant with the Care Quality Commission s Essential Standards of Quality and Safety, Outcome 4, Care and welfare of people who use our services. 3. SCOPE This policy is applicable to all staff who come into contact with patients and/or their records. Page 3 of 12
4 4. RESPONSIBILITIES, ACCOUNTABILITIES and DUTIES 4.1 Board of Directors It is the responsibility of the Board of Directors to have policies in place that meet any legislation, national and local requirements and promote best practice. 4.2 Assistant Directors Assistant Directors are responsible for the implementation of the policy within their specific areas 4.3 Clinical Leads/ Matrons Clinical Leads/Matrons are responsible for making staff aware of the policy and monitoring that it is adhered to, as outlined in Section 7. Reporting any failures to comply with the policy on the Trust s Safeguard Incident Reporting System (IR1) Investigating any failures to comply with the policy and taking corrective action to prevent recurrence Undertaking random checks on the use of /information on wristbands/photographs in their specific areas, using the audit form - Appendix Clinical staff Clinical staff are responsible for adhering to this policy Obtaining/recording/checking the patient s details/identity. Checking the patients identity prior to administration of medicines or treatments Reporting any incidents involving patient misidentification Replacing any wristband that has been removed and checking that the information is valid and accurate For ensuring an up to date photograph is used as appropriate. 4.5 Medical Secretaries/Health Records Admin Staff It is the responsibility of staff that comes into contact with Health Records to ensure patient information is in the correct patient s record and that they adhere to the Trust s Healthcare Records Policy. If duplicate/multiple records are found, the person finding them must report this to the ICT Service Desk on (electronic records) and the relevant Medical Secretaries/Health Records Admin staff for paper records. An IR1, Incident Report must be completed. Page 4 of 12
5 5. PROCEDURE/IMPLEMENTATION 5.1 Patient identification Patient identification starts with the patient s first contact with the service and it is important that the correct details are obtained and recorded. Any inaccuracies or queries that are highlighted should be dealt with immediately or as soon as possible after they become known.see Appendix It is critical that staff acknowledge and accept that the management and monitoring of the patient identification is an ongoing process and not something that happens only on admission or an initial contact Healthcare professionals must not proceed with any treatment or intervention if the patient cannot be positively identified In areas where white boards are used for the location of patients these boards must not be used as a method for patient identification. White boards must be updated following any admission, transfer or discharge. 5.2 Mental Capacity Considerations In order to determine a patient s ability to identify themselves it is important that an assessment of their capacity to be able to do so is undertaken at both the point of admission and other key points during their episode of inpatient care. The Mental Capacity Act 2005 which came into force in October 2007 sets out the statutory framework for making decisions for people who lack capacity to make such decisions themselves. The Act establishes the overarching statutory principles governing these decisions, setting out who can make them and when. It also sets out the legal requirements for assessing whether or not a person lacks the capacity to make a decision. The MCA defines a person who lacks capacity as someone who is unable to make a decision for themselves because of an impairment or disturbance in the functioning of their mind or brain. It does not matter if the disturbance is permanent or temporary. A person lacks capacity if: they have an impairment or disturbance (for example a disability, condition or trauma or the effects of drugs or alcohol) that affects the way their brain or mind works, and that the impairment or disturbance means that they are unable to make a specific decision at the time it needs to be made A person is unable to make a decision if they cannot do one or more of the following: Understand the information given to them that is relevant to the decision Retain the information long enough to make the decision Use or weigh up the information as part of the decision making process Page 5 of 12
6 Communicate their decision. This could include speech, sign language or muscle movements such as blinking or the squeezing of a hand. Full Guidance on how people should be helped to make their own decisions is given in the Mental Capacity Act (2005) Code of Practice and staff are to refer to both this,and the Trust Mental Capacity Act policy. In the event that a patient who lacks capacity refuses to comply with either wearing a wrist band or having their photo taken staff are to refer to their local standard operating procedures for guidance. 5.3 Identification steps STEP 1- By asking the patient to tell you their name (first and surname), date of birth and address and check likeness against photograph (if used). (If an in-patient, check this is compatible with the patient ID wristband minus the address). Do not state their name, date of birth etc and then ask them to confirm or deny by a yes/no reply. STEP 2 -If a patient is unable to tell you their name verify the information by asking family relatives, carers, responsible adult or another member of the clinical staff who knows the patient-to identify the patient by name, date of birth and address. STEP 3- Extreme Emergencies- In extreme emergencies and possible life threatening situations clinical care may take priority over attaching an identity wristband to the patient in an in-patient setting. Where this has occurred, the accountable nurse responsible for patient care Must take appropriate steps to identify the patient using the hospital number. If an in-patient, once the surname, forename, date of birth and NHS Number are confirmed, a new identity wristband MUST be attached to the patient immediately. If a photograph is being used please ensure this is attached securely to the medicine card. Record in the patient s plan of care that identity has been confirmed and name of witness. The person in charge of a ward must make sure that staffs are introduced to new patients at the commencement of their shift or handover. When asking a staff member to undertake an activity they must confirm they know the identity of the patient. 5.4 Wristbands The NPSA believe that it is safest only to use a white wristband with black text The information must be printed onto the wristband and be in indelible black ink It is good practice to site the wristband on the patient s dominant wrist, following their consent. It must be applied to be comfortable but ensure, as far as possible, it cannot be self removed The NPSA recommends that Trust s should use the specified core patient identifiers on wristbands. These are as follows: Page 6 of 12
7 Last Name First Name Date of Birth Patient s NHS Number The first and last name must be clearly differentiated by using lower case letters for first name (with upper case first letter) and UPPER Case for last name. They must be presented in the order of LAST Name, First Name. The date of birth must be DD Mmm-YYYY eg; 01-Jan The NHS number consists of 10 digits the first 9 digits constitute the identifier and the tenth is a check digit that ensures it s validity. Where possible, digits should be displayed as this format aids accuracy and reduces the risk of transposing digits when information is taken from a screen Prior to the wristband being attached, the patient will be asked to read the details on the wristband to confirm that they are correct and if not advise on the corrections If a patient s first language is not English refer to the Trust s Policy for the provision of, access to and use of Interpreters. 5.5 Patients who do not wear wristbands Patients may not wear a wristband for several reasons: They may refuse to wear identity wristbands They may remove wristbands Wristbands cannot be worn due to skin irritation. If the patient is in an area where it is expected that they wear a wristband staff should explain the reasons why it is in their best interests to wear one. If they still refuse the reason why must be documented in their records. Any other agreed alternative method used to identify them should be care planned.. Staff must be extra vigilant and seek other means of positively identifying the patient before any treatment/procedure is given No procedure should be carried out unless the staff member is satisfied they are applying it to the intended individual. If more than one member of staff is seeing a patient, then each one of them is responsible for checking the identity of the patient. 5.6 Photographs In areas where patients do not wear wristbands, photographs should be used. Consent to take a photograph should be obtained from the patient. If they are unable to consent a decision must be made, by staff, in the patient s best interest. Page 7 of 12
8 The photograph must be a good likeness, and updated when necessary. Photographs will be securely attached to the Medicine card. Documents with photographs attached must be kept in a secure area, and at no time left unattended. Photographs will be destroyed when the patient is discharged. If a patient significantly changes their appearance then a new photograph must be taken and replace the old image. Only one photograph per patient shall be used and any other images destroyed and images removed from the camera. On Discharge the photographic image shall be destroyed. Where the local procedure is to have a photographic identification of the patient and they refuse to have one taken, this must be recorded in their specific health record and an agreed alternative method care planned. 5.7 Community Services Staff Check the patient s identity verbally by asking them to state their full name, date of birth and address. Check if they can tell you the purpose of the proposed care delivery. Where the patient is not able to confirm their identity due to their current health or mental capacity, confirm their identity with a known carer, person with parental authority ( if a child) or another member of clinical staff who knows the patient. 5.8 Safety Incidents Any patient safety incidents, including near misses relating to patients who have no wristband or one with incorrect information, must be reported via the Trust Safeguard Incident Reporting System (IR1). The Trust accepts that some services may, in exceptional circumstances, be required to provide immediate intervention or treatment to a patient who is not able to identify themselves due to their clinical condition, and no form of identification can be found on the individual concerned. In an emergency situation immediate actions required will take priority based on risk assessment of the patient s condition. 6. TRAINING IMPLICATIONS There are no specific training requirements. Staff will be made aware of the policy at local induction, team meetings and 1-1 meetings. When the policy is reviewed this will be publicised in the Trust s Weekly Bulletin. Page 8 of 12
9 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Compliance with the policy Number and percentage of patients wearing wristbands Accuracy of information on the wristbands IR1 Reports Matrons Assistant Director Observation Matrons Service Manager Observation Matrons Service Manager When incidents occur Random spot checks Random spot checksusing audit tool (Appendix 1) 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Indicate how this will be met No issues have been identified in relation to this policy. 9. LINKS TO OTHER TRUST PROCEDURAL DOCUMENTS Policy for Consent to Examination or Treatment Policy for provision of,access to and use of Interpreters for Service Users and Carers Mental Capacity Act (2005) Policy Page 9 of 12
10 10. REFERENCES NPSA (2004) Right Patient-Right Care National Patient Safety Agency (2007) Standardising wristbands improves patient safety. Safer Practice Notice No 24 July National Patient Safety Agency (2009) Risk to patient safety of not using the NHS Number as the National Identifier for all patients. NPSA Safer Practice National Patient Safety Agency (2009) Standardising wristbands improves patient safety: Guidance on implementing the Safer Practice Notice (SPN 24, July 2007) and the related information standard on core patient identifiers approved by the Information Standards Board for Health and Social Care in March Department of Constitutional Affairs (2007) Code of Practice Mental Capacity Act (2005) 11. APPENDICES Appendix 1 Audit Form Appendix 2 Flowchart for Patient Identification Process Appendix 3 Adult Inpatient Protocol for Patient Identification Page 10 of 12
11 Appendix 1 PATIENT IDENTIFICATION AUDIT FORM Audit Statement Managers in Clinical areas are required to schedule in an audit of compliance with this policy, 6 months after it s launch and subsequently review. Please note the percentage of in-patients wearing wrist bands within the in-patient area. Please note the percentage of name bands which comply with the standards outlined in this policy Audit the reasons why a patient is not wearing a wristband and state the efficacy of alternative arrangements Review staff awareness of the content of this policy as below: Please survey a minimum of 10 staff or if the team is less than 10 people survey the whole team Is the member of staff aware of the Patient Identification Policy? Can the member of staff list the minimum requirements for patient identification as described in the policy and appropriate to their area of work? Is the member of staff aware of the appropriate action to take if misidentification of a patient occurs? Where NO is recorded as an answer, the manager to note remedial action Page 11 of 12
12 FLOW CHART FOR PATIENT IDENTIFICATION PROCESS Appendix 2 All staff at every patient contact should verify the identification of the patient. This Policy therefore applies equally to the identification of a new service user or to a staff member who is meeting a known individual for the first time and at any subsequent patient contact. In following this process staff must be aware of any communication/ understanding difficulties which may arise through their own use of language, terminology, dialect, accents. Ask the person their name, Verification: Ask the carer/ friend/advocate or other staff member to verify NO address and date of birth information given Ask the person who they are expecting to see and what they expect from the contact Verification: Check that you have the correct referral information/cross reference to the First Name, Last Name, Date of Birth, Unique NHS Identification Number, address, visual observation of person against clinical information given NO Ascertain the Patients level of understanding regarding the treatment or intervention prior to commencing or administering Verification: Visual observation of person against available clinical information/ do you have the correct notes/do you have the correct clinic list/ visit schedule check date does the information correlate to your understanding and the Patient understanding, regarding the care, intervention and treatment? NO Proceed with treatment or intervention required Yes Verification: if necessary check against electronic record systems and or recheck with referral information prior to intervention should a discrepancy occur. If in doubt do not continue until identification is confirmed unless this is an emergency. In an emergency situation immediate actions required will take priority based on risk assessment of the patient condition Record any discrepancies regarding patient identification in the clinical Page 1 record of 12
Patient Identification
Patient Identification Reference No: Version: 5 Ratified by: P_CS_24 LCHS Trust Board Date ratified: 10 th April 2018 Name of originator/author: Name of approving committee/responsible individual: Date
More informationSection 132 of the Mental Health Act 1983 Procedure for Informing Detained Patients of their Legal Rights
Section 132 of the Mental Health Act 1983 Procedure for Informing Detained Patients of their Legal Rights DOCUMENT CONTROL: Version: 11 Ratified by: Mental Health Legislation Sub Committee Date ratified:
More informationPolicy for Patient Identification. Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document Lead:
CONTROLLED DOCUMENT Policy for Patient Identification CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document Lead: Approved By:
More informationProtocol for the Self Administration of Medication within the Locked Rehabilitation and Recovery Inpatient Unit
Protocol for the Self Administration of Medication within the Locked Rehabilitation and Recovery Inpatient Unit DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Assurance Sub Group Date ratified: 28
More informationDOCUMENT CONTROL Patient Identification Policy 6 CL001
Title: Version: Reference Number: Scope: DOCUMENT CONTROL Patient Identification Policy 6 CL001 This policy applies to all staff who work in an inpatient setting and staff accessing inpatient wards. Purpose:
More informationRequesting a Second Opinion Policy
Requesting a Second Opinion Policy DOCUMENT CONTROL: Version: 2 Ratified by: Quality and Safety Sub Committee Date ratified: 31 July 201 Name of originator/author: Doncaster Locality Manager, Adult Mental
More informationHoist and Sling for Safer Patient Use Policy
Hoist and Sling for Safer Patient Use Policy DOCUMENT CONTROL: Version: 4 Ratified by: Quality and Safety Sub Committee Date ratified: 30 January 2017 Name of originator/author: Back Care Advisor Name
More informationGuidelines for In-patient and Residential staff. Staff in Mental Health and Learning Disability In-
Guidelines for In-patient and Residential staff in Mental Health and Learning Disability Services for contacting the On call -Training Grade Doctor/GP DOCUMENT CONTROL Version 4.2 Ratified by Quality and
More informationRESEARCH GOVERNANCE POLICY
RESEARCH GOVERNANCE POLICY DOCUMENT CONTROL: Version: V6 Ratified by: Performance and Assurance Group Date ratified: 12 November 2015 Name of originator/author: Assistant Director of Research Name of responsible
More informationDIAGNOSTIC CLINICAL TESTS AND SCREENING PROCEDURES MANAGEMENT POLICY
DIAGNOSTIC CLINICAL TESTS AND SCREENING PROCEDURES MANAGEMENT POLICY (To be read in conjunction with Diagnostic Imaging Requesting and Interpreting Radiographs by Non Medical Practitioners Policy, Consent
More informationCLINICAL PROTOCOL FOR THE IDENTIFICATION OF SERVICE USERS
CLINICAL PROTOCOL FOR THE IDENTIFICATION OF SERVICE USERS RATIONALE All Professionals/healthcare workers are personally accountable for their practice and, in the exercise of their professional accountability,
More informationAssessment and Care of Children and Young People with Mental Health Needs, who are placed in an Acute General Hospital Ward Policy
Assessment and Care of Children and Young People with Mental Health Needs, who are placed in an Acute General Hospital Ward Policy DOCUMENT CONTROL: Version: 1 Ratified by: Clinical Quality and Standards
More informationStandard Operating Procedure Discharge/Transfer of Patients from St John s Hospice In-Patient Unit
Standard Operating Procedure Discharge/Transfer of Patients from St John s Hospice In-Patient Unit DOCUMENT CONTROL: Version: 1.1 Ratified by: Quality Assurance Sub Committee Date ratified: 2 February
More informationSection 117 Policy The Mental Health Act 1983
Section 117 Policy The Mental Health Act 1983 [as amended by the Mental Health Act 2007] DOCUMENT CONTROL: Version: 1 Ratified by: Mental Health Legislation Committee Date ratified: 2 November 2016 Name
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Pre-Operative Marking
The Newcastle upon Tyne Hospitals NHS Foundation Trust Pre-Operative Marking Version.: 6.1 Effective From: 01 April 2015 Expiry Date: 01 April 2018 Date Ratified: 17 December 2014 Ratified By: Theatre
More informationSafeguarding Children Policy
Safeguarding Children Policy DOCUMENT CONTROL Version: 12.1 Ratified by Quality and Safety Sub Committee Date ratified: 4 September 2017 Name of originator/author: Associate Nurse Director Children s Care
More informationCare Programme Approach (CPA) Policy
Care Programme Approach (CPA) Policy DOCUMENT CONTROL: Version: 10 Ratified by: Quality and Safety Sub Committee Date ratified: 3 May 2017 Name of originator/author: Nurse Consultant, AMHS Name of responsible
More informationDate ratified November Review Date November This Policy supersedes the following document which must now be destroyed:
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Cleaning Policy NTW(O)71 James Duncan Deputy Chief Executive / Executive Director of Finance Steve Blackburn Deputy
More informationPOLICY NO.: POLICY AND PROCEDURE Subject: Patient Identification and Wrist Bands SUPERSEDES: ORIGINAL DATE: PAGE: I. POLICY: II. DEFINITIONS: PC_01
POLICY AND PROCEDURE Subject: Patient Identification and Wrist Bands POLICY NO.: PC_01 ORIGINAL DATE: SUPERSEDES: PAGE: 04/01/1998 12/2012 1 of 6 Key Words: Color Coded Alert, ID Applies to: Inpatient:
More informationAdvance Statements and Advance Decisions to Refuse Treatment Policy
Advance Statements and Advance Decisions to Refuse Treatment Policy DOCUMENT CONTROL: Version: V4 Ratified by: Mental Health Legislation Sub Committee Date ratified: 22 December 2017 Name of originator/author:
More informationPATIENT IDENTIFICATION POLICY
Directorate of Clinical and Quality Assurance & Trust Secretary PATIENT IDENTIFICATION POLICY Reference: CQP021 Version: 2.2 This version issued: 19/09/13 Result of last review: Minor changes Date approved
More informationTRUST POLICY AND PROCEDURES FOR PATIENT IDENTIFICATION
TRUST POLICY AND PROCEDURES FOR PATIENT IDENTIFICATION Reference Number POL-RKM/2133/08 Version: 4 Status: Final Author: Sandra Mir Job Title: Patient Safety and Risk Manager Version / Amendment History
More informationClinical Governance & Risk Management Awareness. Incl. investigation of accidents, complaints and claims. Unit 2
Clinical Governance & Risk Management Awareness Incl. investigation of accidents, complaints and claims Unit 2 Unit 2 Clinical Governance & Risk Management Awareness Including investigation of accidents,
More informationStaff with responsibilities under Section 17 of the Mental Health Act. Section 17, Mental Health Act, authorisation, leave, detained, patients
Policy: Section 17 Mental Health Act - Authorisation of Leave (Detained Patients) Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke, Executive Director
More informationSystmOne COMMUNITY OPERATIONAL GUIDELINES
SystmOne COMMUNITY OPERATIONAL GUIDELINES Guidelines IM&T 11 Date: August 2007 Document Management Title of document SystmOne Community Operational Guidelines Type of document Guidelines IM&T 11 Description
More informationFREQUENTLY ASKED QUESTIONS (FAQS) FOR THE INDIVIDUAL HEALTH IDENTIFIER (IHI) JANUARY 2016
FREQUENTLY ASKED QUESTIONS (FAQS) FOR THE INDIVIDUAL HEALTH IDENTIFIER (IHI) JANUARY 2016 IHI FAQs Version 11.0. 28 January 2016 TABLE OF CONTENTS 1. What is an Individual Health Identifier or IHI?...4
More informationMental Capacity Act Policy V3.00
Mental Capacity Act Policy V3.00 Lead executive Name / title of author: Mandy Bailey Chief Nurse Lesley Shaw, Lead Nurse Vulnerable Adults Date reviewed: October 2015 Date ratified: 13/11/2015 Ratifying
More informationPeterborough Office. Select Support Partnerships Ltd. Overall rating for this service. Inspection report. Ratings. Requires Improvement
Select Support Partnerships Ltd Peterborough Office Inspection report Workspace House 28/29 Maxwell Road Peterborough Cambridgeshire PE2 7JE Tel: 01733396160 Date of inspection visit: 14 June 2017 19 June
More informationClinical Audit Policy
Clinical Audit Policy DOCUMENT CONTROL Version: 5 Ratified by: Quality Assurance Group Date ratified: 3 July 2017 Name of originator/author: Clinical Quality Lead Senior Clinical Audit Facilitator Name
More informationBabylon Healthcare Services
Babylon Healthcare Services Limited Babylon Healthcare Services Ltd. Inspection report 60 Sloane Avenue London SW3 3DD Tel: 0207 1000762 Website: www.babylonhealth.com Date of inspection visit: 4 July
More informationManaging medicines in care homes
Managing medicines in care homes http://www.nice.org.uk/guidance/sc/sc1.jsp Published: 14 March 2014 Contents What is this guideline about and who is it for?... 5 Purpose of this guideline... 5 Audience
More informationDignity and Respect Charter for patients. Version 6.0
Dignity and Respect Charter for patients Version 6.0 Purpose: For use by: This document is compliant with /supports compliance with: To advise and inform hospital staff of the right for all patients, their
More informationMedicines Reconciliation Policy
Medicines Reconciliation Policy Lead executive Medical Director Authors details Senior Clinical Pharmacy Technician - 01244 39 7494 Document level: Trustwide (TW) Code: MP19 Issue number: 3 Type of document
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust
The Newcastle upon Tyne Hospitals NHS Foundation Trust Advance Decision to Refuse Treatment Policy (Advanced Refusal of Treatment/ Previously known as Living Wills) Incorporating the Mental Capacity Act
More informationInformal Patients to take Leave from Adult Mental Health Inpatient Wards. Standard Operating Procedure
Informal Patients to take Leave from Adult Mental Health Inpatient Wards Standard Operating Procedure DOCUMENT CONTROL: Version: 1 Ratified by: Quality Committee Date ratified: 16 June 2016 Name of originator/author:
More informationExecutive Director of Nursing and Chief Operating Officer
Document Title Arrangements for Managing Patients Mental and Physical Health Needs across NTW and the Acute Hospital Trusts Reference Number Lead Officer Author(s) (name and designation) Ratified by NTW(C)15
More informationPlymouth Community Healthcare CIC. Observation Policy ( Mental Health Wards and Plymbridge ) Version 2.3
Plymouth Community Healthcare CIC Observation Policy ( Mental Health Wards and Plymbridge ) Version 2.3 Notice to staff using a paper copy of this guidance The policies and procedures page of Healthnet
More informationSocial care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1
Managing medicines in care homes Social care guideline Published: 14 March 2014 nice.org.uk/guidance/sc1 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).
More informationGuide to the Continuing NHS Healthcare Assessment Process
Guide to the Continuing NHS Healthcare Assessment Process Continuing NHS Healthcare (CHC) is a package of care arranged and funded solely by the NHS, where it has been assessed that the person s primary
More informationStandard Operating Procedure 3 (SOP 3) Template. Advance Decision To Refuse Treatment &Advance Statement
Standard Operating Procedure 3 (SOP 3) Template Advance Decision To Refuse Treatment &Advance Statement The Mental Capacity Act 2005 (MCA) provides the legal framework to empower and protect people over
More informationCARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee
CARERS POLICY Department / Service: Originator: All Associate Director of Patient Experience Accountable Director: Chief Nursing Officer Approved by: Patient & Carers Experience Committee & Trust Management
More informationHEALTHCARE INSPECTORATE WALES SAFEGUARDING AND PROTECTING CHILDREN IN WALES:
HEALTHCARE INSPECTORATE WALES SAFEGUARDING AND PROTECTING CHILDREN IN WALES: A Review of the arrangements in place across the Welsh National Health Service ACTION PLAN - UPDATED August 2010 RECOMMENDATION
More informationPatient safety alert 06
Immediate action Action Update Information request Correct site surgery Surgery performed at the incorrect anatomical site is rare. However, it can be devastating for patients. Correct site surgery (CSS)
More informationMOVING TO ALTERNATIVE PREMISES (SERVICE/TEAM/STAFF) POLICY
MOVING TO ALTERNATIVE PREMISES (SERVICE/TEAM/STAFF) POLICY DOCUMENT CONTROL: Version: 2 Ratified by: Risk Management Sub Group Date ratified: 21 st October 2015 Name of originator/author: Information Governance
More informationPatient Experience Strategy
Patient Experience Strategy 2013 2018 V1.0 May 2013 Graham Nice Chief Nurse Putting excellent community care at the heart of the NHS Page 1 of 26 CONTENTS INTRODUCTION 3 PURPOSE, BACKGROUND AND NATIONAL
More informationGuidance for completing the Internal Agency Investigation Report. This form requires completion within 28 days of the alert being raised.
Guidance for completing the Internal Agency Investigation Report The purpose of this is to support managers completing the Mandatory Internal Agency Investigation Report. This report should be completed
More informationProcedure to Allow Nursing Staff to Dispense Leave and Discharge Medication
Procedure to Allow Nursing Staff to Dispense Leave and Discharge Medication Version 2 minor update June 2013 Procedure Number Replaces Policy No. Ratifying Committee N/a PPPF Date Ratified April 2009 Minor
More informationSample. A guide to development of a hospital blood transfusion Policy at the hospital level. Effective from April Hospital Transfusion Committee
Sample A guide to development of a hospital blood transfusion Policy at the hospital level Name of Policy Blood Transfusion Policy Effective from April 2009 Approved by Hospital Transfusion Committee A
More informationSouth Tyneside NHS Foundation Trust. Clinical Policy. Chaperoning Policy. Review Date June 2011
South Tyneside NHS Foundation Trust Clinical Policy Chaperoning Policy Date Approved by Version Issue Date June 2009 2 June Executive 2009 Director of Nursing & Clinical Services Procedure /Policy number
More informationNHSLA Risk Management Standards
NHSLA Risk Management Standards 2012-13 for NHS Trusts providing Acute Services Brighton and Sussex University Hospitals NHS Trust Level 1 October 2012 Contents Executive Summary... 3 Assessment Outcome...
More informationServices. This policy should be read in conjunction with the following statement:
Policy Number Policy Title IT03 CORPORATE POLICY AND PROCEDURE FOR THE USE OF MOBILE PHONES BY SERVICE USERS IN IN- PATIENT AREAS Accountable Director Eecutive Director of Nursing and Secure Services Author
More informationSFHCHS11 - SQA Code HD2H 04 Undertake personal hygiene for individuals unable to care for themselves
Undertake personal hygiene for individuals unable to care for Overview This standard covers undertaking personal hygiene for those individuals who are unable to care for. This includes care of the skin,
More informationOpen Door Policy (replacing policy no. 030/Clinical)
A member of: Association of UK University Hospitals Open Door Policy (replacing policy no. 030/Clinical) THIS POLICY IS CURRENTLY UNDER REVIEW WITH THE POLICY AUTHOR POLICY NUMBER 138/Clinical POLICY VERSION
More informationClinical record keeping - Adult Mental Health Inpatient Services. Standard Operating Procedure
Clinical record keeping - Adult Mental Health Inpatient Services Standard Operating Procedure DOCUMENT CONTROL: Version: 2 Ratified by: Clinical Effectiveness Committee Date ratified: 03 June 2014 Name
More informationUnit 2 Clinical Governance & Risk Management Awareness
Unit 2 Clinical Governance & Risk Management Awareness Incl. investigation of accidents, complaints and claims Unit 2 Clinical Governance & Risk Management Awareness Including investigation of accidents,
More informationH5V0 04 (SCDHSC3122) Support Individuals to Use Medication in Social Care Settings
H5V0 04 (SCDHSC3122) Support Individuals to Use Medication in Social Care Settings Overview This standard applies to social care workers and identifies the requirements when supporting individuals to use
More informationBlood Transfusion Policy. Version Number: 6.1 Controlled Document Sponsor: Controlled Document Lead: On: December 2014.
Blood Transfusion Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Policy Clinical The policy describes the framework and principles required to deliver best transfusion
More informationLOCKED DOORS AND DOOR CONTROL POLICY
LOCKED DOORS AND DOOR CONTROL POLICY Version: 3 Ratified by: Senior Managers Operational Group Date ratified: November 2013 Title of originator/author: Mental Health Legal Strategies Lead Title of responsible
More informationReconciliation of Medicines on Admission to Hospital
Reconciliation of Medicines on Admission to Hospital Policy Title State previous title where relevant. State if Policy New or Revised Policy Strand Org, HR, Clinical, H&S, Infection Control, Finance For
More informationWhat is this Guide for?
Continuing NHS Healthcare (CHC) is a package of services that is arranged and funded solely by the NHS, for those people who have been assessed as having a primary health need. The issue is one of need.
More informationSafeguarding Children Case File Audit:
Safeguarding Children Case File Audit: Health Visitor and School Nurse records 2012 Jackie Wilkinson & Vicki Spencer Safeguarding Leads LPT Audit Period: January 2012 March 2012 Report Date: June 2012
More informationHow to Apply for your Health Records
How to Apply for your Health Records A Guide for Service Users A Guide for Service Users This leaflet explains how you can apply to Hertfordshire Partnership University NHS Foundation Trust to have access
More informationMULTIDISCIPLINARY MEETINGS FOR COMMUNITY HOSPITALS POLICY
MULTIDISCIPLINARY MEETINGS FOR COMMUNITY HOSPITALS POLICY (To be read in conjunction with Handover Policy) Version: 3 Ratified by: Date ratified: August 2015 Title of originator/author: Title of responsible
More informationACCESS TO HEALTH RECORDS POLICY & PROCEDURE
ACCESS TO HEALTH RECORDS POLICY & PROCEDURE Primary Intranet Location Version Number Next Review Year Next Review Month Legal Services V3 2018 January Current Author Author s Job Title Department Approved
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Procedure for Monitoring of Delayed Transfers of Care
The Newcastle upon Tyne Hospitals NHS Foundation Trust Procedure for Monitoring of Delayed Transfers of Care Version No.: 2.2 Effective From: 17 March 2015 Expiry Date: 17 March 2018 Date Ratified: 25
More informationOn: 23 January 2012 Review Date: January 2015 Distribution: Essential Reading for: Information for:
CONTROLLED DOCUMENT Withholding Treatment Procedure (procedure for managing patients/public who are violent and/or abusive) - Yellow and Red Card Procedures CATEGORY: CLASSIFICATION: PURPOSE Controlled
More informationIdentification of Patient, Resident or Client Using Two Identifiers
Approved by: Vice President & Chief Medical Officer; and Vice President & Chief Operating Officer Identification of Patient, Resident or Client Using Two Corporate Policy & Procedures Manual Date Approved
More informationConsent Policy and Procedure (Including Incapacity and Advance Directives)
Consent Policy and Procedure (Including Incapacity and Advance Directives) Policy Statement The Phyllis Tuckwell Hospice is committed to providing high quality care based on patients giving their informed
More informationCentral Alerting System (CAS) Policy
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray
More informationEAST & NORTH HERTS, HERTS VALLEYS CCGS SAFEGUARDING CHILDREN & LOOKED AFTER CHILDREN TRAINING STRATEGY
EAST & NORTH HERTS, HERTS VALLEYS CCGS Page 1 of 16 DOCUMENT CONTROL SHEET Document Owner: Directors of Nursing and Quality Document Author(s): Beverly Mukandi - Deputy Designated Nurse Safeguarding Children,
More informationManual Handling Policy
Document Profile Box Document Reference: Version: 0001 Ratified by: Health and Safety Committee Date ratified: Aug 2008 Name of originator/author: Alan Gallagher Name of responsible committee/individual:
More informationDOCUMENT CONTROL Title: Use of Mobile Phones and Tablets (by services users & visitors in clinical areas) Policy. Version: Reference Number: CL062
DOCUMENT CONTROL Title: Version: Reference Number: Use of Mobile Phones and Tablets (by services users & visitors in clinical areas) Policy 5 CL062 Scope: This Policy applies all employees of the Trust,
More informationSAFEGUARDING CHILDREN POLICY
SAFEGUARDING CHILDREN POLICY The child s needs are paramount, and the needs and wishes of each child, be they a baby or infant, or an older child, should be put first Working Together 2015 p 8 Keeping
More informationPerformance and Quality Committee
Title: NHS Continuing Health Care Choice Policy (addendum to Cornwall Wide Patient Choice, Equity and Fair Access Policy) Developed by: Document type: Policy library: NHS Kernow Policy Policies Sub Section:
More informationCare of the Adult Patient Following Death (last Offices) Standard Operating Procedure (SOP)
Care of the Adult Patient Following Death (last Offices) Standard Operating Procedure (SOP) DOCUMENT CONTROL: Version: 2 Ratified by: Quality and Safety Sub Committee Date ratified: 27 February 2017 (specific
More informationInforming Patients of their Rights under Section 132
Policy: I9 Informing Patients of their Rights under Section 132 Version: I9/05 Ratified by: Trust Management Team Date ratified: 12 June 2013 Title of Author: MHA Office / Health Records Manager Title
More informationEssential Nursing and Care Services
Essential Nursing & Care Services Ltd Essential Nursing and Care Services Inspection report Unit 7 Concept Park, Innovation Close Poole Dorset BH12 4QT Date of inspection visit: 09 February 2016 10 February
More informationVisual Communication Alert Symbols Guidelines for Staff. Version 4.0. All Hospital Staff. Care Quality Commission s fundamental standards
Visual Communication Alert Symbols Guidelines for Staff Version 4.0 Purpose: To inform hospital staff of the process for ensuring that patients are treated with dignity and respect through providing visual
More informationAgenda Item: REPORT TO PUBLIC BOARD MEETING 31 May 2012
Agenda Item: 5.1.1 REPORT TO PUBLIC BOARD MEETING 31 May 2012 Title Lead Director Author(s) Purpose Previously considered by Ratification of the Strategy for the Care of Older People Siobhan Jordan, Director
More informationAction Plan for Kingfisher Lodge
Action Plan for Kingfisher Lodge Dear Sir or Madam, We thought it might be useful to residents, potential residents, their relatives and friends to summarise our response to the Care Quality Commission
More informationNHS RESEARCH PASSPORT POLICY AND PROCEDURE
LEEDS BECKETT UNIVERSITY NHS RESEARCH PASSPORT POLICY AND PROCEDURE www.leedsbeckett.ac.uk/staff 1. Introduction This policy aims to clarify the circumstances in which an NHS Honorary Research Contract
More informationSection 7: Core clinical headings
Section 7: Core clinical headings Core clinical heading standards: the core clinical headings are those that are the priority for inclusion in EHRs, as they are generally items that are the priority for
More informationThe Mental Capacity Act 2005 Legislation and Deprivation of Liberties (DOLs) Authorisation Policy
The Mental Capacity Act 2005 Legislation and Deprivation of Liberties (DOLs) Authorisation Policy Version Number 3 Version Date vember 2015 Policy Owner Director of Nursing and Clinical Governance Author
More informationSFHCHS10 - SQA Code HD2L 04 Undertake stoma care
Overview This standard covers undertaking the care of a bowel/bladder stoma. This may be for individuals with new stomas or for individuals with established stomas who are unable to manage their own stoma
More informationPolicy Document Control Page
Policy Document Control Page Title: Section 17 (Leave of Absence) Policy Version: 9 Reference Number: CL7 Supersedes Supersedes: Section 17 (Leave of Absence) Policy V8 Description of Amendment(s): Updated
More informationNon Attendance (Did Not Attend-DNA ) Policy. Executive Director of Nursing and Chief Operating Officer
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Non Attendance (Did Not Attend-DNA) NTW(C)06 Executive Director of Nursing and Chief Operating Officer Ann Marshall
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Injectable Medicines Policy
The Newcastle upon Tyne Hospitals NHS Foundation Trust Injectable Medicines Policy Version No.: 4.3 Effective From: 24 March 2017 Expiry Date: 21 January 2019 Date Ratified: 11 January 2017 Ratified By:
More informationPROCEDURE FOR MEDICINES RECONCILIATION BY NURSING STAFF FOR PATIENTS ADMITTED TO THE COMMUNITY HOSPITALS OUT OF HOURS
PROCEDURE FOR MEDICINES RECONCILIATION BY NURSING STAFF FOR PATIENTS ADMITTED TO THE COMMUNITY HOSPITALS OUT OF HOURS Policy Details NHFT document reference MMPr030 Version 22/02/16 Date Ratified May 2016
More informationADMITTING YOUNG PEOPLE UNDER 18 TO ADULT MENTAL HEALTH WARDS POLICY
ADMITTING YOUNG PEOPLE UNDER 18 TO ADULT MENTAL HEALTH WARDS POLICY Version: 2 Ratified By: Date Ratified: August 2015 Title of Originator/Author Title of Responsible Committee/Group Senior Managers Operational
More informationPositive and Safe Management of Post incident Support and Debrief. Ron Weddle Deputy Director, Positive and Safe Care
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Positive and Safe Management of Post incident Support and Debrief NTW(C)13 Ron Weddle Deputy Director, Positive
More informationPOLICY FOR INCIDENT AND SERIOUS INCIDENT REPORTING
POLICY FOR INCIDENT AND SERIOUS INCIDENT REPORTING Policy Acceptance Applies to: All staff, patients, & carers Date Issued: 7 th March 2016 Status Ratified Version 4 Date for Review March 2018 Responsible
More informationMajor Change. Outline of the information that has been added to this document especially where it may change what staff need to do
Policy Number LCH-45 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational
More informationContinuing Healthcare Policy
Continuing Healthcare Policy 1 SUMMARY This policy describes the way in which Haringey Clinical Commissioning Group (HCCG) will make provision for the care of people who have been assessed as eligible
More informationPregnancy Information Sharing Pathway for Safeguarding Children (Midwifery, Health Visiting and Primary Care)
Pregnancy Information Sharing Pathway for Safeguarding Children (Midwifery, Health Visiting and Primary Care) July 2010 Originator: Women and Child Health /Primary Care/Safeguarding Team Submitted by:
More informationInterpretation and Translation Services Policy
Interpretation and Translation Services Policy This is a new procedural document. Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee
More informationLearning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care.
Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Associated Policies Being Open and Duty of Candour policy CG10 Clinical incident / near-miss
More informationMedical Needs Policy. Policy Date: March 2017
Medical Needs Policy Policy Date: March 2017 Renewal Date: March 2017 Equality Statement This policy takes into account the provisions of the Equality Act 2010 and advances equal opportunities for all.
More informationSafeguarding Vulnerable Adults Policy
POLICY & PROCEDURES PROTECTION OF VULNERABLE ADULTS This policy was written in conjunction with the Multi-Agency Safeguarding of Vulnerable Adults in Lincolnshire Policy STATEMENT The welfare of all vulnerable
More informationAssessment criteria for obtaining a venous blood sample
Core blood competencies assessment framework Assessment criteria for obtaining a venous blood sample This framework is for assessing the candidates ability in obtaining a venous blood sample for transfusion.
More informationPharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02
Pharmacological Therapy Practice Guidance Note Medicine Reconciliation on Admission to Hospital for Adults in all Clinical Areas within NTW V02 V02 issued Issue 1 May 11 Issue 2 Dec 11 Planned review May
More information