Salisbury Foundation Trust

FOI_4817

Internal Reference Number: FOI_4817

Date Request Received: 14/01/2019 15:40:25

Date Request Replied To: 18/02/2019 10:20:28

This response was sent via: By Email

Request Summary: Documentation relating to health records/ EPR inc. strategies, implementation plans, risk logs etc.

Request Category: Health










































 
Question Number 1:
Please provide all strategies relating to health records (electronic or paper health records) at your Trust
 
Answer To Question 1:
No current strategy
 
Question Number 2:
Please provide all policies relating to health records (electronic or paper health records) at your Trust
 
Answer To Question 2:
See attached documentsDocument 1 - Creation Use and Management Healthcare Records.pdfDocument 10 - Lorenzo SOP (Recording Alerts).pdfDocument 11 - Lorenzo SOP (Clinical Documentation).pdfDocument 12 - Lorenzo Guidance (Tracking records).pdfDocument 13 - Lorenzo Guidancce (locating notes).pdfDocument 14 - Lorenzo Guidance (How to register a baby).pdfDocument 15 - Lorenzo Guidance (Creating casenotes for babies).pdfDocument 16 - The Coding Process.pdfDocument 2 - Retention and Disposal of Healthcare Records.pdfDocument 3 - Amendments to Healthcare Records (electronic).pdfDocument 4 - Amendments to Healthcare Records (paper).pdfDocument 5 - Transferring Records to a Local Place of Deposit.pdfDocument 6 - Access to Personal and Healthcare Information.pdfDocument 7 - Lorenzo SOP (Casente Management).pdfDocument 8 - Lorenzo SOP (Duplicate Record Management).pdfDocument 9 - Lorenzo SOP (Updating Patient Details and Registrations).pdf
 
Question Number 3:
In relation to the implementation of EPR, Clinical EDMS at your Trust, please provide:
a. Implementation plans
b. Project plans
c. Project issue/risk logs
 
Answer To Question 3:
No current plans
 
Question Number 4:
In relation to the transition from paper to digital health records at your Trust, please provide:
a. Any paper to digital transition plans
b. Benefit realisation documents
 
Answer To Question 4:
a. Digital Strategy has been re-written and is going through approval process. Due for publication in March
b. N/A
 
Question Number 5:
In relation to paperless/paperlite outpatient consultations at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 5:
a. Policies - no formal policy in place at present as paperlight working has been piloted in two small areas at present and is not in use trust wide.
b. Procedures - see process maps and quick ref guides attached
c. Processes - maps included in attachments
d. Guidance documents - see attached docs
e. Process maps - see attached documents
f. Process flowcharts - see attached documents
g. Service standards/KPIs - not applicable for small pilot

Creating a Clinical Chart from an Inpatient Pegboard V6 27.09.2018.pdfQRG Admin Clinical Chart (set up from clinic pegboard) 16.05.18 V2 (CP).pdfQRG Admin Clinical Chart (set up from clinic pegboard) 30.08.18 V4 (CP) rheum.pdfQRG Admin Clinical Chart (set up from patient's EPR) 16.05.18 V2 (CP).pdfQRG Admin Clinical Chart (set up from patient's EPR)29.08.2018 V3 (CP) rheum.pdfQRG Clinician Clinial Charts 18.05.2018 V2 (CP).pdfQRG Clinician Clinial Charts 30.08.2018 V4 Rheum.pdfQRG Rheum clinical chart Managing clinical documentation for secretaries V3 30.08.2018.pdfRheumatology Clinical Chart scanning.pdfScoping Document for Clinical Chart Roll out 14.12.17.pdfSFT 01 Orthotic Admin Process V0.1.pdfSFT 01 Orthotic Clinical Process V0.1.pdf
 
Question Number 6:
In relation to the creation of health records for new patients in acute admission wards/emergency departments at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 6:
Please see documents 1, 9, 12 and 13 in Question 2
 
Question Number 7:
In relation to the provision and delivery of health records to clinical staff for existing/already known patients in acute admission wards/emergency departments at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 7:
Please see answer for Question 6
 
Question Number 8:
In relation to the creation of health records for babies delivered at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 8:
Please see documents 14 and 15 in Question 2
 
Question Number 9:
In relation to the management and prevention of loose clinical documentation/health records at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 9:
Contained within Document 1 in Question 2
 
Question Number 10:
In relation to the management and prevention of missing or misplaced clinical documentation/health records at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 10:
Please see document 12 in question 2. SOP under development for this one
 
Question Number 11:
In relation to health records held within E-Referral Service/Choose & Book such as referral letters, how is this shared with, accessed through or manually copied onto your EPR/EDMS at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 11:
Please see attachmentQRG eRS Downloading Process.pdf
 
Question Number 12:
In relation to the integration of community and acute health records at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 12:
No community records are integrated
 
Question Number 13:
In relation to the health record documentation sources defined for use by clinical coders at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
 
Answer To Question 13:
Please see document 16 in Question 2
 
Question Number 14:
In relation to any health records management functions provided by non-NHS suppliers at your Trust, please provide:
a. Policies
b. Procedures
c. Processes
d. Guidance documents
e. Process maps
f. Process flowcharts
g. Service standards/KPIs
h. Any information demonstrating benefits attributable to these arrangements
 
Answer To Question 14:
The only non NHS supplier is Restore where maternity and some deceased notes are stored.
They follow the policies detailed in the answer to Q2
Please see attachments:
QRG eRS Downloading Process.doc
QRG eRS Downloading Process.pdf
Document 1 - Creation Use and Management Healthcare Records.pdf
Document 10 - Lorenzo SOP (Recording Alerts).pdf
Document 11 - Lorenzo SOP (Clinical Documentation).pdf
Document 12 - Lorenzo Guidance (Tracking records).pdf
Document 13 - Lorenzo Guidancce (locating notes).pdf
Document 14 - Lorenzo Guidance (How to register a baby).pdf
Document 15 - Lorenzo Guidance (Creating casenotes for babies).pdf
Document 16 - The Coding Process.docx
Document 16 - The Coding Process.pdf
Document 2 - Retention and Disposal of Healthcare Records.pdf
Document 3 - Amendments to Healthcare Records (electronic).pdf
Document 4 - Amendments to Healthcare Records (paper).pdf
Document 5 - Transferring Records to a Local Place of Deposit.pdf
Document 6 - Access to Personal and Healthcare Information.pdf
Document 7 - Lorenzo SOP (Casente Management).pdf
Document 8 - Lorenzo SOP (Duplicate Record Management).pdf
Document 9 - Lorenzo SOP (Updating Patient Details and Registrations).pdf
Creating a Clinical Chart from an Inpatient Pegboard V6 27.09.2018.docx
Creating a Clinical Chart from an Inpatient Pegboard V6 27.09.2018.pdf
QRG Admin Clinical Chart (set up from clinic pegboard) 16.05.18 V2 (CP).doc
QRG Admin Clinical Chart (set up from clinic pegboard) 16.05.18 V2 (CP).pdf
QRG Admin Clinical Chart (set up from clinic pegboard) 30.08.18 V4 (CP) rheum.pdf
QRG Admin Clinical Chart (set up from patient's EPR) 16.05.18 V2 (CP).docx
QRG Admin Clinical Chart (set up from patient's EPR) 16.05.18 V2 (CP).pdf
QRG Admin Clinical Chart (set up from patient's EPR)29.08.2018 V3 (CP) rheum.pdf
QRG Clinician Clinial Charts 18.05.2018 V2 (CP).doc
QRG Clinician Clinial Charts 18.05.2018 V2 (CP).pdf
QRG Clinician Clinial Charts 30.08.2018 V4 Rheum.pdf
QRG Rheum clinical chart Managing clinical documentation for secretaries V3 30.08.2018.pdf
Rheumatology Clinical Chart scanning.docx
Rheumatology Clinical Chart scanning.pdf
Scoping Document for Clinical Chart Roll out 14.12.17.docx
Scoping Document for Clinical Chart Roll out 14.12.17.pdf
SFT 01 Orthotic Admin Process V0.1.pdf
SFT 01 Orthotic Clinical Process V0.1.pdf
 
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