Requesting, Locating and Tracking Patient Records Policy

Transcription

1 Requesting, Locating and Tracking Patient Records Policy This procedural document supersedes: Policy for the Requesting, Locating and Tracking Patient Records CORP/REC 4 v.4 This policy should be used in conjunction with CORP/REC 5 - Clinical Records Policy CORP/REC 6 - Record Keeping Standards Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours. Author/reviewer: (this version) Date written/revised: March 2015 Approved by: Ratified by: Julie Robinson Medical Records Manager Doncaster & Bassetlaw Hospital Clinical Records Committee Date Ratified: 31 March 2015 Date issued: 1 April 2015 Next review date: March 2017 Target audience: Policy Approval and Compliance Group Trust-wide Page 1 of 17

2 Amendment Form Version Date Issued Brief Summary of Changes Author Version 5 1 April 2015 Change in process point 4.1v)-paragraph 2 Julie Robinson 4.3-to read manager at the end of the paragraph Clinical Records Committee 4.4 and 4.5 amalgamated and service delivery times changed 4.7 Tracking codes added 6.2 Weekly spot check reduced to 10 casenotes as agreed at CRC-please refer to CORP/REC 1 Order of Filing Hospital Casenotes Policy Appendix 3-RMP10 Searching for Misfiles Creating Temporary Folders Appendix 4-Equality Impact Assessment Version 4 February Major changes throughout PLEASE READ IN FULL Christine Coates 2012 Introduction updated Purpose identified Guidance on requesting patient records updated Guidance on confidentiality of patient records during transfer added Tracker location maintenance and sub location guidance added Casenote retrieval contact details updated. Contact details for Maternity casenote retrieval added Instructions for returning casenotes to casenote libraries added; use of in transit codes Tracking of casenotes received in medical records libraries added Education and training guidance added Processes for monitoring compliance added Links to other associated procedural documents added Reference to local procedural document for checking for missing patient records added Version 3 March 2009 Amendment form added Contents added Minor changes made throughout Contact numbers updated Version 2 November Section 1, paragraph 4 has been amended to 2006 include guidance on miscellaneous filing Section 4, additional section to cover location of casenotes at Tickhill Road Hospital Page 2 of 17 Christine Coates/ Clinical Records Sub-committee Christine Coates/ June Hines

3 Section Contents 1 Introduction 4 2 Equality Impact Assessment 4 3 Purpose 4 4 Duties and Responsibilities Requesting Patient Records Transferring Patient Records to Another Location Tracker Location Maintenance and Sub Location Facility 6 Page No. 4.4 Patient Record Enquiries, Requests and Transfers by non-pas users and PAS users 6 Appendices 4.5 Locating Casenotes Outside Normal Working Office Hours PAS Users Returning Patient Records to Casenote Libraries Tracking casenotes Received by Medical Records Libraries 8 5 Education and Training 8 6 Monitoring Compliance with the Procedural Document Key Performance Indicators (KPI s) Casenote Structure, Filing and Tracking Audit 9 7 Associated Procedural Documents 9 Appendix 1 Notice-Removal of casenotes from a clinic preparation area 10 Appendix 2 Appendix 3 Guidelines for Storage and Destruction of Patient Information held by Macmillan Specialist Palliative Care Nurses RMP10 - Searching for Misfiles, Creating Temporary Folders and Merging Casenotes with Temporary Folders Appendix 4 Equality Impact Assessment Page 3 of 17

4 1. INTRODUCTION The movement of all patient records must be recorded to provide an effective casenote location and retrieval service. The Casenote Manager module of the Patient Administration System (PAS) recognises patients NHS and district numbers, treatment numbers and/or the demographic details with which patient s are registered on the PAS. All PAS users have access to Tracker. It is essential that staff across the Trust update Tracker whenever they move casenotes. The system entirely replaces manual procedures for tracing case notes both in and out of filing locations and between other locations. It supports real-time case note requests, enquiries and movements. The use of Casenote Manager increases efficiency by reducing the need for telephone calls; it improves the flow of case notes around the organisation. Staff should refer to the Tracker User Guide for detailed guidance on using the system, which describes the functionality and facilities offered. If users have difficulty tracking casenotes they should contact a medical records department supervisor or the PAS training department for further advice. 2. EQUALITY IMPACT ASSESSMENT An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment For All Policy (CORP/EMP 4). The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. (See Appendix 4). 3. PURPOSE To ensure that patient records are available at the right place at the right time when needed. 4. DUTIES AND RESPONSIBILITIES 4.1 Requesting Patient Records i) Search PAS Tracker to establish the current location of the patient's records. ii) Records located in the Medical Records Library at Bassetlaw Hospital should be requested via the PAS Tracker Request Facility. A telephone answer phone service is available for urgent casenote requests on ext Urgent requests will be given priority. Page 4 of 17

5 Records tracked to any other location at Bassetlaw Hospital should be requested by telephone, directly to the location. iii) iv) Records located in any Medical Records Libraries at Doncaster Royal Infirmary, should be requested by telephone, directly to the current location. Records located in the Medical Records Library at Montagu Hospital should be requested via the PAS Tracker Request Facility. A telephone answer phone service is available for urgent casenote requests on ext Urgent requests will be given priority. v) Medical Records departments do not accept requests for casenotes needed for miscellaneous filing to be undertaken in other areas:- At Doncaster Royal Infirmary it is the responsibility of staff to locate and retrieve the casenotes themselves from the Medical Records Libraries. Bassetlaw Hospital has a closed Medical Records Library - Casenotes required for filing should be requested via the Tracker request facility. - The casenotes will be retrieved from library by the medical records staff, tracked to their intended destination, and will be collected and delivered via the porters at the end of each working day Montagu Hospital has a closed Medical Records Library - Casenotes required for filing should be requested via the Tracker request facility. - The casenotes will be extracted from file by the medical records staff, tracked to the collection area in the department. After filing has been undertaken, the casenotes must be Tracked and returned to file by the requester. 4.2 Transferring Patient Records to another Location i) The transfer of patient records out of a location must be recorded on Tracker, this is mandatory. ii) Individual users, eg secretaries, must track records into their own sub-locations. iii) Clinic notes should be tracked to the appropriate clinic code and will then be the responsibility of the outpatient department or relevant secretary, until they are tracked to another location or back and delivered to a Medical Records department. iv) Individual users are responsible for tracking records into and out of their own locations. It is not the responsibility of Medical Records staff. v) Individual users are responsible for locating all casenotes still tracked to their locations, unless the casenotes are in transit. It is not the responsibility of Medical Records staff. vi) To maintain patient confidentiality, envelopes containing casenotes must be securely sealed and clearly addressed to the medical records department at the relative hospital site. vii) Tote boxes carrying casenotes must be clearly addressed and sealed with a tie wrap to ensure confidentiality. Page 5 of 17

6 4.3 Tracker Location Maintenance and Sub Location Facility It is possible to set up a two-tier location structure which enables a set of case notes to be recorded precisely e.g. down to a shelf or drawer if necessary. When required additional casenote locations and sub locations can be added to the system at any time by contacting a medical records manager. 4.4 Patient Record Enquiries, Requests and Transfers by non-pas Users and PAS users All enquiries, requests and transfers of patient records by non-pas users, advice and support must be sought from any health records department. Requests for casenotes for emergency retrieval are as follows; General Records, DRI Resus requests for casenotes tracked to 3636/6567/3033/3741/4034/6556/3032/3739/3632 General Records between the hours of 8am-5pm Monday to Friday Monday-Friday 8am-5pm 8321 Saturday/Sunday 9am-5pm Bleep 1850 Monday-Sunday 5pm-8am Bleep 1850 Bank Holiday Bleep 1850 Saturday/Sunday 8am-9am A&E department 3245/4102 Tickhill Road Hospital Out of normal office hours Bleep holder via switchboard at Tickhill Road Orthopaedic Records, DRI Monday-Friday 8am-5pm 4623/6533 Saturday/Sunday 9am-5pm Bleep 1850 Monday-Sunday 5pm-8am Bleep 1850 Bank Holiday Bleep 1850 Saturday/Sunday 8am-9am A&E department 3245/4102 Maternity Records, DRI Monday-Friday 8am-5pm 3266/3174/3158/3265 Saturday/Sunday 9am-5pm Bleep 1850 Monday-Sunday 5pm-8am Bleep 1850 Bank Holiday Bleep 1850 Saturday/Sunday 8am-9am A&E department 3245/4102 Bassetlaw Records Monday-Friday 8am-5pm 2795 Saturday/Sunday A&E department 2067 Monday-Sunday 5pm-8am A&E department 2067 Bank Holiday A&E department 2067 Montagu Records Monday-Friday 8am-8.30am 5293/5313 Monday-Friday 4.30pm-5pm 5293/5313 Monday-Friday 8.30am-4.30pm 5269 Saturday/Sunday Bleep lead nurse via switchboard Bank Holiday Bleep lead nurse via switchboard Page 6 of 17

7 When the casenotes have been located, the bleep holder will contact the requester. If required at another hospital site to confirm the transport arrangement and confirm the delivery/collection point. The casenotes will be tracked to the required location by the Medical Records Clerk. If casenotes are tracked to Tickhill Road Hospital, Location and retrieval of casenotes out of hours is via the Bleep holder, who should be contacted via the main switchboard. If the casenotes are located, the Bleep holder will contact the original requester to confirm and ask for transport to be arranged to collect the notes. If the Bleep holder cannot find the casenotes in their current Tracker location, additional information is available in the bleep book about where casenotes may otherwise be located. The Bleep holder will leave a written message for the relevant medical secretary or department staff that the casenotes have been removed. The Bleep holder will notify the requester that the securely enveloped and clearly addressed casenotes are available at the main switchboard for collection. 4.5 Locating Casenotes Outside Normal Office Hours For patient records required outside medical records normal office hours the following procedure should be followed:- i) Check PAS to find the correct unit number for the patient, if registered, and confirm if casenotes exist for the patient. ii) iii) iv) Access Tracker and establish the current location of the patient's records. Provide the patient s name, casenote number, current location (if available) on Tracker including the shelf or cabinet within an office or department as noted on Tracker. State the required destination and contact telephone number. In the event of the patient records not being found in their Tracked location, Medical Records Guidelines for Checking for Missing Patient Records should be followed.(rmp10 - Searching for Misfiles Creating Temporary Folders) - Appendix 3 If a temporary set of casenotes is required, due to a missing set of casenotes, this must be reported by raising an incident on the Datix incident system. It is the responsibility of the staff member requiring the casenotes to raise the incident form. Page 7 of 17

8 If casenotes are removed from a clinic preparation area or clinic location, before removing them a form (sample attached Appendix 1) notifying that the patient records have been removed from the location, must be completed. 4.6 PAS Users Returning Patient Records to Casenote Libraries Track all casenote folders to the relevant In Transit to File tracker location Code. BFILE - In transit to file - Bassetlaw Records Department DGFILE - In transit to file - DRI General Records Department DOFILE - In transit to file - DRI Orthopaedic Records Department DAFILE - In transit to file - DRI Antenatal Records Department PFILE - In transit to file - DRI Maternity Records Department (Post Natal Store) MFILE - In transit to file - Montagu Records Department Individual volumes of District numbered casenotes must be tracked. 4.7 Tracking Casenotes Received by Medical Records Libraries Medical records departments will Track casenotes to the relevant casenote library location before returning them to file:- RMFILE -Filed Bassetlaw Records Department FILED -Filed DRI General Records Department FILEDO -Filed DRI Orthopaedic Records Department FILEDA -Filed DRI Antenatal Records Department FILEDP -Filed DRI Maternity Records Department (Post Natal Store) FILEDM -Filed Montagu Records Department 5. EDUCATION AND TRAINING PAS access is restricted to trained staff. Training is available for all PAS users; new staff in areas that use PAS must attend formal training delivered by the PAS training team. Individual line Page 8 of 17

9 managers are responsible for arranging training by completing a computer services on line training request form. PAS Training Documents & User Guides are given to all attendees, copies can also be downloaded from the intranet. 6. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT 6.1 Key Performance Indicators (KPI s) Medical Records department performance is measured on key performance indicators. The KPI s include accurate tracking of casenotes on despatch and return to medical records departments. Non-compliance by non medical records department staff is reportable to relevant line managers or the PAS data quality sub group for action. A monthly Stock Location Report of casenotes tracked to location MCN (missing casenotes) must be printed from Tracker for Key Performance Indicator reporting. This will be carried out by all Health Records Supervisors and reported to the General Manager via KPI s. 6.2 Casenote Structure, Filing and Tracking Audit CORP/REC 1 Policy for the Order of Filing in Hospital casenotes requires that each medical records department must monitor compliance with this policy by undertaking a weekly spot check of 10 casenotes using the audit form attached to the policy. Audit action reports are submitted to the Patient Safety Review Group. 7. ASSOCIATED TRUST PROCEDURAL DOCUMENTS CORP/REC 1 - Policy for the Order of Filing in Hospital Casenotes CORP/REC 2 - Policy for Safeguarding Patient Records Held Separately from Medical Records Libraries and in Transit CORP/REC 5 Clinical Records Policy Page 9 of 17

10 APPENDIX 1 NOTICE-REMOVAL OF CASENOTES FROM A CLINIC PREPARATION AREA! IMPORTANT NOTICE! THESE NOTES ARE NOT TO BE REMOVED FROM THIS CLINIC BOX WITHOUT COMPLETING THE TABLE BELOW These notes have been pulled and tracked to a clinic. It is essential that the clinic clerk is kept informed of removals to ensure that the records are obtained for the patient s out-patient clinic appointment. Your co-operation in this matter is appreciated. CASENOTE NUMBER NAME LOCATION Page 10 of 17 THANK YOU

11 APPENDIX 2 Guidelines for Storage and Destruction of Patient Information held by Macmillan Specialist Palliative Care Nurses Name of author Date revised March 2015 Approved by (Committee/Group) Date issued July 2009 Review date March 2017 Target audience: Sandra Salmon - Macmillan Nurse Specialist/ Palliative Care Nurse, on behalf of the Specialist Palliative Care Team Clinical Records Sub-committee Trust-wide Page 11 of 17

12 Guidelines for Storage and Destruction of Patient Information held by Macmillan Specialist Palliative Care Nurses 1. INTRODUCTION Prior to 2005 the Macmillan specialist palliative care nurses stored patient assessment records in their offices. In order to comply with NHSLA guidance patient records are now inserted directly into the patient s clinical notes. By the nature of the specialist palliative care service, carers may telephone the nurses for advice or information during the patient s admission or after discharge or bereavement. The nurses may also give telephone advice to health care professionals regarding symptom management if an immediate visit to the ward is not possible e.g. D.R.I. based nurses may be asked for advice for patients at Montagu or Bassetlaw hospitals. In order to provide safe well coordinated care as advised in Improving Supportive and Palliative care for Adults with Cancer (NICE 2004), it will be necessary for brief notes to be stored for a limited period in the Macmillan offices. These notes comprise patient and carer contact details and any advice or information given regarding symptom management. The Clinical Records Committee has agreed to these notes being stored for a period of up to 18 months after the patient s discharge or death, and then to be destroyed by shredding. 2. AIM To provide safe well coordinated care. To store and dispose of office held notes correctly. 3. ACTIONS 3.1 Brief notes of patient and carer contact details and care and symptom management advice to be stored in a locked cupboard in the Macmillan offices. When the office is left unattended, the doors and windows are to be locked. 1.2 Any information recorded about in-patients, following telephone discussions, to be transferred to the patient s medical records in a timely manner. 3.3 Office held notes to be destroyed by shredding up to 18 months after patient discharge or death. 4. REFERENCES National Institute for Clinical Excellence (2004) Improving Supportive and Palliative Care for Adults with Cancer, London. Page 12 of 17

13 APPENDIX 3 RMP10 DONCASTER & BASSETLAW HOSPITALS NHS FOUNDATION TRUST Searching for Misfiles, Creating Temporary Folders and Merging Casenotes with Temporary Folders When casenote folders have been tracked to a medical records department FILED location but cannot be located, the following process must be followed and recorded on Appendix A. Medical Records Departments will: 1. Check the Patient Master Index on PAS to ensure that the missing casenote number and the patients number on PAS are the same. 2. Check that the patient has not been double registered; may be attending on another number, the folders may have been merged. 3. Check Tracker, the patient may have multiple numbers / folders that have been renumbered under the district number. 4. Check the filing system for the missing folder under the old six digit treatment number and under the new seven digit district number. 5. Check Tracker for the location of the other volumes/folders and check with those locations. 6. If the other volume/s are not at the tracked location, check Tracker for details of other the previous locations. 7. Check the hospital attendance screen on PAS and back track through other departments/secretaries etc. where the casenotes may have been returned and not tracked. 8. Check the out-patient and in-patient screens on PAS for any recent /outstanding appointments or recent / future admissions. 9. Check amongst casenotes waiting to be filed. 10. Check amongst casenotes awaiting collection. 11. Check with C.D.C. if the patient has been an in-patient. 12. If the patient attends under any other consultant, ring the department or secretary. 13. Check if the casenotes have been accidently filed in a secondary filing location. 14. Check the deceased casenotes. 15. Check with medical records departments at alternative sites. Page 13 of 17

14 Searching for Misfiles e.g. Number e.g. D Check the middle digits in terminal digit section 67 i.e Check the number in terminal digit section 60-69, looking nearer the number first, i.e. sections 66 and Check the whole terminal digit section Check the whole bay Also consider: 0 looks like 6 1 looks like 7 2 looks like 3 3 looks like 2 or 5 or 8 5 looks like 3 or 8 6 looks like 0 or 6 7 looks like 1 8 looks like 5 or 6 9 looks like 1 or 8 or 0 5. Request a Tracker Report for casenotes tracked to the relevant FILED location i.e. FILEDB FILED FILEDO - Filed Bassetlaw Records Department - Filed DRI General Records Department - Filed DRI Orthopaedic Records Department FILEDA FILEDP FILEDM - Filed DRI Antenatal Records Department - Filed DRI DRI Maternity Records Post Natal Store - Filed Montagu Records Department 6. Check in the filing system next to casenotes filed around the same time, same day. 7. Look for similar numbers and check those areas of the filing system. Page 14 of 17

15 Creating Temporary Casenotes Folders See RMP1 - Returning Casenotes to Casenote Libraries and Responsibility for Locating Casenotes Tracking Temporary Casenote Folders 1. When transferring temporary folders, if the original number is entered a warning is given that a temporary folder exists. 2. When transferring a temporary folder the number must be entered in the format T1. Monitoring A monthly Stock Location Report of casenotes tracked to location MCN (missing casenotes) must be printed from Tracker for Key Performance Indicator reporting. This will be carried out by all Health Records Supervisors and reported to the General Manager via KPI s. Merging a Temporary Folder with the Original Folder and Merging on Tracker See RMP1 - Returning Casenotes to Casenote Libraries and Responsibility for Locating Casenotes Written by: Julie Robinson, Health Records Manager Page 15 of 17

16 CORP/REC 4 v.5 Appendix A - for RMP10 Looking for Missing Notes tracked to file checklist. Date Patient Number Patient Name Filed By, Date and Time. PAS checked to see if patient is admitted or seen anywhere else after notes have been tracked to file. Check all middle digit, i.e. number from Check number in terminal digit, checking numbers nearest first, i.e checking 55 and 57 first. Swap numbers around in terminal digit i.e check , and Check whole bay of casenotes i.e check all 56. Check audit list for what was filed before and after to see if 2 sets of casenotes have been picked up together. Check for double registration and incorrect merging. Check with consultants secretary and places the patient has attended in the past, including CDC if patient has been admitted. Check Clinical Audit department. Yes or No Comments Clerk Supervisor... Page 16 of 17

17 APPENDIX 4 EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING Service/Function/Policy/Project/ Care Group/Executive Assessor (s) New or Existing Service or Date of Assessment Strategy Directorate and Department Policy? Requesting, Locating and Tracking Patient Records Policy Diagnostics & Pharmacy Care Group Julie Robinson Existing policy March ) Who is responsible for this policy? Diagnostics & Pharmacy Care Group 2) Describe the purpose of the service / function / policy / project/ strategy? To provide guidance on the tracking and requesting of patient records 3) Are there any associated objectives? National casenote standards Records Code of Practice 4) What factors contribute or detract from achieving intended outcomes? Non-compliance 5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership, maternity/pregnancy and religion/belief? No If yes, please describe current or planned activities to address the impact 6) Is there any scope for new measures which would promote equality? No 7) Are any of the following groups adversely affected by the policy? No Protected Characteristics Affected? Impact a) Age No b) Disability No c) Gender No d) Gender Reassignment No e) Marriage/Civil Partnership No f) Maternity/Pregnancy No g) Race No h) Religion/Belief No i) Sexual Orientation No 8) Provide the Equality Rating of the service / function /policy / project / strategy tick () outcome box Outcome 1 Outcome 2 Outcome 3 Outcome 4 *If you have rated the policy as having an outcome of 2, 3 or 4, it is necessary to carry out a detailed assessment and complete a Detailed Equality Analysis form in Appendix 4 Date for next review: March 2017 Checked by: Julie Robinson Date: March 2015 Page 17 of 17