Clinical RiO Health Records Policy

Transcription

1 Clinical RiO Health Records Policy Interim Additional Health Records Policy for Teams Involved in Clinical RiO Rollout Note this Policy must be read in conjunction with Health Records Policy Version: 1.2 Ratified by: Information Governance Steering Group Date ratified: January 2012 Name of originator/author: Head of Information Governance Name of responsible committee/individual: IGSG Circulated to: All staff Date issued: August 2012 Review date: December 2012 Target audience: Services involved in RiO clinical implementation 1

2 Version Control Summary Version Date Author Status Comment 1.0 January 2012 Head of Information Governance Final Interim policy for teams involved in RiO clinical implementation. This policy is in addition to the Health Records policy and must be read in conjunction with it 1.1 February 2012 Head of Information Governance Final Clarification on use of process notes 1.2 August 2012 Head of Information Governance Final Incident form document attach types added 2

3 Contents Paragraph Page 1.0 Introduction Purpose Principles Associated documentation 5 3

4 1.0 Introduction This policy is only relevant to services involved in RiO clinical implementation. Although the Health Records policy provides the overarching framework for achieving high quality safe record keeping, it is based on the principle that the primary clinical record is held in paper format. The Electronic Clinical Systems Programme Board agreed in November 2011 to a phased implementation of clinical RiO where the electronic record replaces the paper record as the primary record. During the implementation phase there will be some services whose primary records become electronic and some services whose primary records remain paper based. In the early stages of implementation the majority of services will remain paper based. This interim additional policy is therefore aimed at those services involved in clinical RiO implementation to provide an appropriate framework for managing an electronic model of record keeping. This interim additional policy will be merged with the Health Records policy in due course. 2.0 Purpose This policy therefore sets out the standards and processes required for maintaining high quality electronic health record keeping standards. Note that all standards contained in the Health Records policy generally continue to apply except where reference is made to the paper record being the primary record. For services implementing clinical RiO any such references should be ignored although the same standards apply generally to all record formats. Any specific references to filing paper copies in the case notes should similarly be ignored. The Trust will maintain separate guidance documents, procedures and training events to support individuals in the implementation of this policy. These are referenced where appropriate. Further information can be found on the information governance pages and the RiO user guide pages on the intranet. 3.0 Principles For services involved in clinical RiO implementation: Only Trust approved scanners will be used for scanning documents All information about a service user received electronically will be uploaded to RiO All information about a service user received in paper format will be scanned and subsequently uploaded to RiO The record on RiO will be the primary record. No other current records will be kept other than the temporary folder outlined below. All original paper and electronic information will therefore be deleted once the scanned copy on RiO has been verified as attaining the same standard as the originating copy. This is to prevent duplication of systems and information and the potential for information to be missed, incorrectly added to or otherwise inappropriately processed A temporary paper folder of specific documents (also listed in the RiO crib sheet Storage and destruction of clinical paper records ) will be retained by the service for 4

5 the duration of the episode of care to assist in the event of RiO unavailability, temporary overnight transfer to another inpatient ward or the Homerton hospital etc. No other documents will be kept in the temporary folder First Person Care Plan Prescription charts/depot charts Observation forms Outcome measurement and other questionnaires The written copy of the CPA form with signatures Sticky labels with patient details to order investigations. A print out of the registration form The original current care plan Copy of current risk assessment Practical constraints e.g. Patient property etc Mental Health Act documents (this does not include police documentation which should be uploaded to RiO) Alerts that have an immediate impact on patient care Do not resuscitate forms All documents in the temporary folder will be destroyed once the episode of care is completed except for the list below. These should be kept as a non electronic record filed with the paper record: MHA documentation Prescription / depot charts Observation forms Results / investigations / bloods Practical constraints e.g. patient property receipts Audio / video recordings Patient artwork and other documentation not in standard scan-able format Process notes will not be uploaded to RiO. They will normally be retained in paper format by the therapist during the service user s course of treatment and subsequently deleted when the course of treatment is complete unless the therapist believes there is value in retention The processes on the RiO user guide pages on the intranet will be followed at all times Teams will set up a systematic process for alerting all members of the treating team to newly received and uploaded information including incoming electronic and paper documents Where teams or individuals outside the treating team add information to RiO they will routinely alert the treating team to raise awareness of any immediate or significant issues Clinicians will routinely check RiO for newly received information prior to an appointment / intervention with a service user Correspondence should never be filed in RiO unsigned. Typed correspondence must always contain an electronic signature. Where the clinician prefers to delegate authority to an administrator for adding the signature, this should be confirmed by and the also retained in RiO When RiO is unavailable paper records should be scanned and temporarily held in the team folder on the K drive. Electronic records should similarly be temporarily held 5

6 on the K drive rather than individual mailboxes or H drives. When RiO becomes available priority should be given to uploading documents Electronic records on RiO will be subject to the same retention and deletion periods as paper records (i.e. the retention period does not alter simply because the format is electronic rather than paper) Electronic records on RiO will be subject to regular audit including record keeping standards and legitimate relationship access to records. This may include targeted audits Records pre-dating clinical RiO implementation will be retained in paper format and will not currently be uploaded to RiO except in instances where the Responsible Clinician believes there is distinct value in doing so Requests for access to records will be centrally managed by the Access to Records leads, including supervised access for solicitors requiring access to the service user s record on RiO. In instances where the solicitor requires access to both current information on RiO and the previous paper record, the Access to Records lead will arrange for the paper copy to be available centrally 4.0 Associated documentation This policy should be read in conjunction with the information governance and clinical policies on the intranet 6