Reference 2019-43

REF: 2019-43

Subject: Health records management

 

Request:

1. Please provide all strategies relating to health records (electronic or paper health records) at your Trust

2. Please provide all policies relating to health records (electronic or paper health records) at your Trust

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

 

Response:

Please find information attached.

2019-43 – FOI Request – Health records management [135 kb] PDF

Records Management Policy June 2018 [611 kb] PDF

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