This is an official Northern Trust policy and should not be edited in any way Orthopaedic ICATS Administrative Process Reference Number: NHSCT/12/537 Target audience: This policy covers all administrative staff working within Orthopaedic ICATS Sources of advice in relation to this document: Suzanne Kennedy, Team Leader, Orthopaedic ICATS Rebecca Getty, Assistant Director Acute Services Operational Support Replaces (if appropriate): NHSCT Orthopaedic ICATS Administration Process (NHSCT/10/255) Type of Document: Directorate Specific Approved by: Rebecca Getty, Assistant Director Acute Services Operational Support Date Approved: 9 May 2012 Date Issued by Policy Unit: 30 May 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves
Orthopaedic ICATS Administrative Process Introduction This guideline details the administrative process to be followed by staff working within the Orthopaedic ICATS service. The Northern Trust Physiotherapy, Podiatry, Administrative and ICATS managers, and all staff within Orthopaedic ICATS have been adequately consulted in the drawing up of this guideline, which represents their consensus view. Aim To ensure a consistent approach to how all referrals are dealt with, and to ensure referrals are dealt with in a timely manner. To ensure that all staff adhere to the correct procedures and ensure they fulfil their role in a confident, competent and professional manner. Policy Statement This policy details the administrative processes for the day to day running of the Orthopaedic ICATS service. Target Audience This policy covers all administrative staff working within Orthopaedic ICATS. Responsibilities It is the responsibility of all staff to familiarise themselves with, and adhere to the contents of this guideline. Legislative Compliance The guideline has been developed with reference to the DHSS&PS Operational Booking Process. The guideline should be read in conjunction with the following procedures/guidelines: - Integrated Elective Access Protocol CSP Core Standards Northern Trust Orthopaedic ICATS Policy on Clinical Triage; Ordering Diagnostics N.I. Clinical Guidelines for Practitioners working within ICATS for Musculoskeletal Conditions 2
Recommendations Receiving Referrals Referrals are received and are triaged by clinical staff following the Orthopaedic ICATS clinical triage policy. Admin staff make up the patient s chart as per Records Management. Letters Patients who are being accepted into ICATS who require a 1 st letter. Patients are given 5 days to respond from the date of letter. Generate a first letter using the approved template Print two copies Send original to patient Place the file copy in the patient s chart. File the chart in 1 st letter file under the date letter was sent. Patient s who require a 2 nd letter i.e. patient s who have not responded to their 1 st letter within 5 working days. Admin staff should check the patient s demographic details by phoning the GP surgery to confirm patient s details are correct e.g. address and telephone number. If details are correct send a 2 nd letter, allowing 5 working days for the patient to make contact. Print two copies Send original to patient Place the file copy in the patient s chart. File the chart in 2 st letter file under the date letter was sent. If the details held on database were incorrect: Update the database. Send the 1 st letter again to the correct address Print 2 copies of the letter, post the original to the patient, and file the copy in the patient s chart. Place the patient s chart in the 1 st letter file to ensure that the patient has 5 working days to respond. Send a second letter, as per protocol, if there is no response to the initial letter. Patients who do not respond to the 2 nd DISCHARGED. letter within 5 working days are 3
Administration process: Remove the patient s chart from 2 nd letter file. Complete the Discharge section of the database Send a non-response letter to the patient s GP, and place a copy in the patient s chart. Send a discharge letter to patient, and place a copy in the patient s chart. File the chart for discharge Should patients make contact after this deadline they should be informed that a new referral from their GP is required. In exceptional circumstances for example where a patient has been in hospital it is reasonable to offer an appointment without a new referral. Appointments Process for making appointments in response to receipt 1 st or 2 nd letters. When the patient phones, ask them for the reference at the top of their letter Ask the patient to confirm their address and telephone number (or any other contact number) Update the database with any new details Ask for the date on their letter Retrieve their chart from the 1 st or 2 nd letter file Check the chart for clinic, body part, clinician required e.g. Podiatrist/Physiotherapist Check if x-ray is required If a new x-ray has been requested as indicated on the triage page. Admin inform patient of this and that radiology will contact them for an appointment. Inform patient that if they DNA their diagnostic appointment, they will be discharged. Arrange a suitable appointment time with patient Enter onto the database. Write the appointment on front of the patients chart with appointed clinician. (Appointment should be given at the earliest convenience but must be within 6 weeks) Inform patient that if they DNA, they will be discharged A confirmation letter is sent to patient Insert a copy of the letter into the patient s chart File the chart under the date of appointment or place chart in tray for clinician to order diagnostic if required Review appointments Review appointment must be made within six weeks of being seen Appointments should be made in agreement with the patient Give the patient an appointment card The appointment should be written onto patient record sheet Place the patient s chart for filing under date of appointment given 4
Interpreting service/sign language Should an interpreter be required a one-hour appointment should be allowed The interpreter must be booked in line with the Trust s Equality Unit guidelines Cancellations / DNA S If a patient DNA s their first ICATS appointment or their diagnostic appointment, the following process must be implemented: Where a patient has had an opportunity to agree the date and time of their appointment, and does not attend, they will not normally be offered a second appointment. These patients will be referred back to the care of their referring GP. Send a DNA letter to both the GP and the patient. Place a copy of both letters into the patient chart. Under exceptional circumstances a clinician may decide that a patient should be offered a second appointment. The second appointment must be partially booked, i.e. Appointment time agreed with the patient. Complete the discharge section on the database Complete the records management label File the chart for discharge. If a patient cancels their appointment the following process must be implemented: 1. The patient will be given a second opportunity to book an appointment, which should be within six weeks of the original appointment date. 2. If a second appointment is cancelled, the patient will be referred back to their referring GP for a new referral. 3. Complete the discharge section of the database 4. Complete the records management label 5. File the chart for discharge. 6. Patients will only be reinstated in exceptional circumstances. Maximum Waiting Time Guarantee If a patient requests an appointment date beyond the maximum waiting time, the patient will be discharged and told to revisit their GP when they are ready to be seen in the clinic. This will ensure that all patients waiting for an outpatient appointment or diagnostic service are fit and ready to attend. Daily Administration Processes Partial Booking telephone lines to be manned from 9am to 5pm. Admin to log on clinical outcomes daily. Referrals to be taken off the system daily and logged on when triaged. 5
1 st and 2 nd Letter Files - Check first and second letter files and letter. Post review, DNA, self-discharge letters. Check for diagnostics completed and send out review appointments. All letters to be posted daily. Referrals to Orthopaedics, Pain Clinic, Rheumatology to be recorded on database before posting. All mail should be ready for collection each day by 12 noon and sorted into two bundles external mail and internal mail. It should be stamped accordingly. All incoming mail should be opened daily and date stamped. Record incoming insoles received and post out or letter patient. Filing kept up to date daily. Log orthotic prescriptions and post to gait lab. Discharges to be records managed daily, logged onto database and stored. Clinics prepared on a daily basis and print clinic lists. Messages recorded in message book when received. Dictation of letters daily all letters should be completed within 1 week. Type urgent letters as priority and then in clinic date order. Stock/non stock deliveries Stock items are ordered by admin staff Team leads order non-stock items. All deliveries of Stock and Non Stock items should be checked off accurately by Admin staff on arrival, and stored in appropriate area. Delivery dockets or relevant paperwork should be checked and the delivery docket attached to relevant requisition number in stock book If non stock - copy should be taken of blue buying order blue order signed and forwarded to Accounts, Finance Department, BVH and the copy attached to the relevant requisition number in the non-stock book. Any discrepancies in the order should be reported on day of delivery. 6
Monitoring and Review The ICATS Manager, Clinical Team Lead and Admin manager are responsible for monitoring the effectiveness of the measures in place with regard to ordering further investigations. The ICATS Manager, Clinical Team Lead and Admin manager should review their local arrangements in accordance with the timescales/guideline/risk Assessment, if circumstances change or following any significant incident. Equality, Human Rights and DDA This policy has been drawn up and reviewed in the light of Section 75 of the Northern Ireland Act (1998) which requires the Trust to have due regard to the need to promote equality of opportunity. It has been screened to identify any adverse impact on the 9 equality categories and no significant differential impacts were identified, therefore, an Equality Impact Assessment is not required. Alternative formats This document can be made available on request on disc, larger font, Braille, audiocassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. 7