Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Examinations under IR(ME)R
|
|
- Sheila Blanche Washington
- 7 years ago
- Views:
Transcription
1 Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging V3.0 December 2013 Page 1 of 11
2 Table of Contents 1. Introduction Purpose of this Policy/Procedure Scope Definitions / Glossary Ownership and Responsibilities Standards and Practice Dissemination and Implementation Monitoring compliance and effectiveness Updating and Review Equality and Diversity... 7 Appendix 1. Governance Information... 8 Appendix 2. Initial Equality Impact Assessment Form Page 2 of 11
3 1. Introduction 1.1. This procedure is designed to enable non medical clinicians to refer patients for clinical imaging This version supersedes any previous versions of this document. 2. Purpose of this Policy/Procedure 2.1. The purpose of this policy is to provide a mechanism through which nonmedically qualified staff may refer patients for clinical imaging The document details the clinical governance, training and education required for the role of referrer under the Ionising Radiation (medical exposure) Regulations, known as (IR(ME)R), 2006, the MHRA (2007) recommendations for Magnetic Resonance Imaging (MRI), NPSA (2007) Safer Practice Notice 16 and Medicines (Administration Radioactive) Substances (MARS) 1978). 3. Scope This document is designed to support non medical clinicians or their clinical supervisors through the authorisation process. 4. Definitions / Glossary 4.1 Referrer: Describes the clinician who has met training and governance requirements to request clinical imaging. 4.2 Practitioner: Justifies the requests by ensuring net benefit and appropriateness to clinical care 4.3Operator: Clinician who acquires the imaging. 5 Ownership and Responsibilities 5.1 The document and all related radiology procedures are owned and managed by the Clinical Imaging Service. 5.2 The Clinical Imaging Department is responsible for ensuring those wishing to undertake the role have acceptable protocols in order to comply with the regulations and recommendations that govern our practice. 5.3 Role of the Managers Line managers are responsible for: The non-medical referrer s clinical supervisor and line manager, are responsible for ensuring that the appropriate training has been undertaken to allow this extended role, any training must satisfy the regulatory bodies, RCHT Radiation Protection Advisor and the Professional Lead within Clinical Imaging.. Page 3 of 11
4 5.4 Role of the Clinical Imaging Clinical Governance Group The Clinical Imaging Clinical Governance Group is responsible for: The ratification of protocols prior to Trust approval. This will be evidenced by the additional signatory. 5.5 Role of Individual Staff All staff members are responsible for: The non-medical referrer must have received sufficient training and be assessed as competent to make clinical imaging referrals. 6 Standards and Practice 6.1 Referrals It is the responsibility of the referrer to provide sufficient information to enable the justification of the examination and clarify its expectations. The examination must have a net benefit (i.e. the exposure of the patient to radiation or strong magnetic fields is warranted) and be justified in accordance with the Royal College of Radiologists irefer guidance; the clinical imaging team will decline any referrals that are considered inappropriate. All referrals must be legible and should indicate clearly the name and role of the referrer e.g. Triage Nurse, Community Nurse, Extended Role Physiotherapist In order for the most appropriate examination to be performed the referral must provide the following information regarding the region to be examined and relevant clinical information. The examinations requested must be stated in the clinical imaging protocol otherwise the referral must be discussed with the responsible medical referrer who must also sign the paper referral or make an electronic referral. If the referrer requires guidance, they must seek advice from a medical referrer and where appropriate a radiologist or radiographer prior to the referral. All referrals must be in keeping with IR(ME)R/ MRI referrer protocols in relation to women of childbearing age. It is the referrer s responsibility to check pregnancy status prior to requesting clinical imaging. 6.2 Interpretation The Clinical Imaging Department is responsible for acquiring, analyzing and reporting of diagnostic images, to enable non-medical referrer s to make an informed clinical decision. In the case of unexpected or adverse findings including those outside of the referrer s scope of practice, the professional and clinical responsibility to act on the information appropriately remains with the referrer. The referrer must discuss the findings with the medical clinician who holds overall responsibility for the patient i.e. Consultant/ General Practitioner. Depending upon the urgency of the case this must be immediate action or within the next working day. Page 4 of 11
5 6.3 Image Interpretation Outside of the Clinical Imaging Department For non- medical staff (other than reporting radiographers) responsible for the initial interpretation of plain film radiographs an appropriate education programme must be completed. The results of the image interpretation must be documented within the patient s record and signed by the clinician (medical or non-medical) who undertook the analysis If the findings are adverse or unexpected, the referrer (even if not the responsible medical clinician) retains the duty of care to act on this result appropriately. As detailed in section 6.2, the referrer must discuss the findings with the referrer and medical clinician who hold overall responsibility for the patient i.e. Consultant/ General Practitioner. Depending upon the urgency of the case this must be immediate action or within the next working day. 6.4 IR(ME)R Referrer Education 6.4.1The referrer must meet the requirements relevant to the modality they are requesting (i.e. IR(ME)R, MRI Safety). Non-medical referrers should also consult professional guidance, for example the Guidance for Clinical Imaging Requests from Non-Medically Qualified Professionals (RCR, 2008) which is supported by several professional bodies The clinical imaging service will not provide training in patient assessment or the appropriate use of radiology as a diagnostic tool; this is the responsibility of the requesting department and clinical supervisor For referrer s requesting MRI examinations, training in MRI safety is provided by the MRI team a minimum half day attendance to the department is required. For RCHT employees requesting examinations under IR(ME)R, on-line training is available through the learning management system (LMS); community teams will be given access to on-line training and asked to complete a declaration form. Page 5 of 11
6 6.5 Gaining approval for IR(ME)R referrer Clinical/Service need for non-medical referrer is established The department/ practitioner wishing to undertake the role approaches the Consultant Radiographer in Clinical Imaging to: Discuss their clinical role, Whether this is a new service or replaces medical referrals The imaging they would like to request, The number of patients they anticipate to refer Practitioner(s) must develop a protocol which defines their practice in relation to imaging, (see appendix A), supply a scope of practice and undertake IR(ME)R/MRI/US referrer training. Evidence of training must be demonstrated to the imaging department before the approval of the protocol(s) through a declaration form (CIF.02) obtainable from the imaging service. Each member of staff who will be undertaking the role must sign an entitlement form (supplied by the imaging department) to provide a specimen signature. Each non-medical referrer who will be undertaking the role must sign an entitlement form (CIF.01 supplied by the imaging department) to provide a specimen signature. Each non-medical referrer must complete an Entitlement Form (CIF.01) which is approved by clinical imaging department; the practitioner is then entered onto the departmental database, a request is made to IT for the referrer to be available on CRIS. If appropriate, Maxims accounts are upgraded to gold. A confirmation letter is sent to the Practitioner The non- medical referrer receives written confirmation of approval and requesting rights. Page 6 of 11
7 7 Dissemination and Implementation 7.1 Documents are shared on the Trust documents library 8 Monitoring compliance and effectiveness Element to be monitored Lead Approval process in section 6.5 Governance & Quality Radiographer Tool Frequency Reporting arrangements Ensure audit trail is correct Annually CICG This will be documented in minutes of the meeting The lead or committee is expected to read and interrogate the report to identify deficiencies in the system and act upon them Acting on recommendations and Lead(s) Change in practice and lessons to be shared Governance Radiographer is responsible for acting upon findings within agreed timescales Required actions will be identified and completed in a specified timeframe Consider stating this responsibility in committee terms of reference Learning will be shared with relevant referrer s/teams. Evidence of this will be through CICG minutes. 9 Updating and Review 9.1 Document will be reviewed 3 yearly unless practice dictates otherwise. 9.2 Revisions can be made ahead of the review date when the procedural document requires updating. Where the revisions are significant and the overall policy is changed, the author should ensure the revised document is taken through the standard consultation, approval and dissemination processes. 9.3 Where the revisions are minor, e.g. amended job titles or changes in the organisational structure, approval can be sought from the Executive Director responsible for signatory approval, and can be re-published accordingly without having gone through the full consultation and ratification process. 9.4 Any revision activity is to be recorded in the Version Control Table as part of the document control process. 10 Equality and Diversity This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 7 of 11
8 Appendix 1. Governance Information Document Title Date Issued/Approved: 4 December 2013 CI.REF.01 Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and Imaging Date Valid From: 4 December 2013 Date Valid To: 4 December 2016 Directorate / Department responsible (author/owner): Christine Bloor, Consultant Radiographer Naomi Burden, Governance Radiographer Contact details: Brief summary of contents Procedure to authorise non medical clinicians to request imaging procedures. Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: October 2013 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: X-ray, MRI, CT. Ultrasound, nuclear medicine, imaging, radiology, IR(ME)R, MARS, ARSAC, MHRA, non-medical referrer, referrals. RCHT PCH CFT KCCG Director of Nursing, Midwifery and Allied Health Professions. Procedure for Non-Medical Staff who wish to Request MRI, Ultrasound and X-ray Examinations under IR(ME)R CICG Bruce Daniel, DGM CSSC Emma Spouse, Diagnostics Lead {Original Copy Signed} Internet & Intranet Page 8 of 11 Clinical / Clinical Imaging Intranet Only IRMER, MARS, MHRA, CQC RCHT Patient Identification Policy
9 Training Need Identified? RCHT Consent to Treatment/Examination RCHT Standards of Record keeping RCHT Infection Control RCHT Radiation Safety Policy Ionising Radiation (medical exposure) Regulations Royal College of Nursing Guidance for Clinical Imaging Requests from Non-Medically Qualified Professionals NPSA16 Safer Practice Notice: Early Identification Of Failure To Act On Radiological Imaging Reports. No Version Control Table Date Versio n No Summary of Changes Nov New documented created Sept Reformatted and approved Oct Reformatted and nuclear medicine added Changes Made by (Name and Job Title) Naomi Burden Governance Radiographer Christine Bloor Consultant Radiographer Naomi Burden Governance Radiographer All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 9 of 11
10 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Directorate and service area: Is this a new or existing Policy? Existing Clinical Imaging Name of individual completing Telephone: assessment: N. Burden 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Procedure to authorise non medical clinicians to request imaging procedures. 2. Policy Objectives* Demonstrates the standards and expectations of the Imaging Department when considering and approving non medical requesting. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? Maintain high standards Demonstrate compliance with regulations Yearly audit of the process Patients NO b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age x No impact on this group. Page 10 of 11
11 Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership x x x x x No impact on this group. No impact on this group. No impact on this group. No impact on this group. No impact on this group. Pregnancy and maternity x No impact on this group. Sexual Orientation, x No impact on this group. Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. The aim of the procedure is to facilitate patient care, there is no impact in any of the groups. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 11 of 11
CLINICAL IMAGING REFERRAL PROTOCOL FOR REGISTERED HEALTHCARE PRACTITIONERS EMPLOYED WITHIN MINOR INJURY UNITS IN CORNWALL
CLINICAL IMAGING REFERRAL PROTOCOL FOR REGISTERED HEALTHCARE PRACTITIONERS EMPLOYED WITHIN MINOR 1. Aim/Purpose of this Guideline This Protocol applies to Registered Healthcare Practitioners in the Minor
More informationCLINICAL GUIDELINE FOR ADVANCED NURSE PRACTITIONER HEPATOLOGY (GASTROENTEROLOGY) 1. Aim/Purpose of this Guideline:
CLINICAL GUIDELINE FOR ADVANCED NURSE PRACTITIONER HEPATOLOGY (GASTROENTEROLOGY) 1. Aim/Purpose of this Guideline: 1.1. This protocol applies to Advanced Nurse Practitioners (Hepatology) employed by RCHT
More informationAccounts Receivable - Guidance to staff responsible for the collection of income following the supply of goods or services V4.0
Accounts Receivable - Guidance to staff responsible for the collection of income following the supply of goods or services V4.0 June 2015 Table of Contents Accounts Receivable - Guidance to staff responsible
More informationSEPSIS IN INFANTS AND CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
SEPSIS IN INFANTS AND CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. This guideline is for the management of sepsis in Infants and children. For full guidance please see the Surviving
More informationCLINICAL GUIDELINE FOR THE USE OF INTRAVENOUS SLIDING SCALE REGIMEN FOR ADULTS 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR THE USE OF INTRAVENOUS SLIDING SCALE REGIMEN FOR ADULTS 1. Aim/Purpose of this Guideline This guideline is for the management of for the management of Adult patients with Diabetes
More informationOccupational Therapy Service in the Emergency Department at Royal Cornwall Hospital V1.0
Occupational Therapy Service in the Emergency Department at Royal Cornwall Hospital V1.0 January 2014 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope... 3 4. Ownership
More informationCLINICAL GUIDELINE FOR THE MANAGEMENT OF HYPERGLYCAEMIA IN ADULTS WITH ACUTE CORONARY SYNDROME
CLINICAL GUIDELINE FOR THE MANAGEMENT OF HYPERGLYCAEMIA IN ADULTS WITH ACUTE CORONARY SYNDROME 1. Aim/Purpose of this Guideline This guideline is for the management of Adult patients with Diabetes Mellitus
More informationGuidance on Leases and other Agreements V4.0
Guidance on Leases and other Agreements V4.0 August 2014 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope... 3 4. Definitions / Glossary... 3 5. Ownership and Responsibilities...
More information2.1 When a breastfeeding woman is admitted to hospital, the support she needs depends on the nature of her illness and the treatment needed
CARE OF BREASTFEEDING WOMEN ADMITTED TO HOSPITAL, CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1 Breastfeeding is known to be one of the most powerful health protective influences and as such,
More informationCLINICAL GUIDELINE FOR CHANGING A CATHETER EXIT SITE DRESSING (I.E. MIDLINE/ CVC/ PICC/ HICKMAN) Summary. Start
CLINICAL GUIDELINE FOR CHANGING A CATHETER EXIT SITE DRESSING (I.E. MIDLINE/ CVC/ PICC/ HICKMAN) Summary. Start 1. Assemble all your equipment before you start. 2. Explain and discuss the procedure with
More informationCLINICAL GUIDELINE HOW TO PERFORM A VENESECTION, DETAILING VEIN SELECTION AND PATIENT CARE 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE HOW TO PERFORM A VENESECTION, DETAILING VEIN SELECTION AND PATIENT CARE 1. Aim/Purpose of this Guideline 1.1. Venesection is a clinical procedure commonly performed in the Haematology
More informationThis guideline is for the management of Adult patients with Diabetes Mellitus using insulin pump therapy during admission to hospital
CLINICAL GUIDELINE FOR THE MANAGEMENT OF ADULT PATIENTS DIABETES MELLITUS USING INSULIN PUMP THERAPY (Continuous Subcutaneous Insulin Infusion (CSII)), DURING ADMISSION TO HOSPITAL 1. Aim/Purpose of this
More information2.1. Applicable areas: Royal Cornwall Hospitals Trust; Neonatal Unit and Delivery Suite
ADVANCED NEONATAL NURSE PRACTITIONERS (ANNPs) BLOOD COMPONENT AND BLOOD PRODUCT REQUESTING PROTOCOL NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1 The purpose of this protocol is to guide
More informationDiagnostic Testing Procedures for Ophthalmic Science
V3.0 09/06/15 Table of Contents 1. Introduction... 3 2. Purpose of this Policy... 3 3. Scope... 3 4. Definitions / Glossary... 3 5. Ownership and Responsibilities... 3 5.2. Role of the Managers... 3 5.3.
More informationMANAGEMENT OF DIRECT ANTIGLOBULIN TEST (DAT) POSITIVE INFANTS NEONATAL CLINICAL GUIDELINE
MANAGEMENT OF DIRECT ANTIGLOBULIN TEST (DAT) POSITIVE INFANTS NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. To provide monitoring and treatment guidance for medical and nursing staff
More informationPREGNANCY OF UNKNOWN LOCATION (PUL) - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
PREGNANCY OF UNKNOWN LOCATION (PUL) - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline All clinical staff working in the Division of women, children & sexual health to provide evidence based guidance
More informationAccess Control Policy V1.0
V1.0 January 2014 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope... 3 4. Definitions / Glossary... 4 5. Ownership and Responsibilities... 4 5.1. Role of the Chief
More informationThe Use of Electronic signatures for Prescribing Chemotherapy and data entries on the Aria MedOncology system V3.0
The Use of Electronic signatures for Prescribing Chemotherapy and data entries on the Aria MedOncology system V3.0 January 2013 Table of Contents 1. Introduction... 3 2. Purpose of this Policy... 3 3.
More informationA Policy for the Trial and Evaluation of Medical Devices
29/05/2014 V2.1 Table of Contents 1. Introduction... 3 2. Purpose of this Policy... 3 3. Scope... 3 4. Definitions... 3 5. Ownership and Responsibilities... 4 5.1. Role of the Trust Board and Medical Director...
More informationHow To Pay A Bill At The Trust
Guidance to Staff responsible for the Ordering, Authorising and Payment of goods and services received V3.0 June 2015 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3.
More informationOXYGEN THERAPY AND SATURATION MONITORING OF THE NEONATE - CLINICAL GUIDELINE
OYGEN THERAPY AND SATURATION MONITORING OF THE NEONATE - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1 To provide guidance on the assessment and management of infants requiring oxygen therapy
More informationGrievance and Disputes Policy and Procedure. Document Title. Date Issued/Approved: 10 August 2010. Date Valid From: 21 December 2015
POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department
More informationCLINICAL GUIDELINE FOR
CLINICAL GUIDELINE FOR the investigation and management of inpatients with discitis (vertebral osteomyelitis) 1. Aim/Purpose of this Guideline 1.1.This guideline applies to clinical staff managing patients
More informationSTROKE AND TIA MULTIDISCIPLINARY CARE PATHWAY 6 th Edition Cornwall Stroke Service (Royal Cornwall Hospital Trust Facing)
STROKE AND TIA MULTIDISCIPLINARY CARE PATHWAY 6 th Edition Cornwall Stroke Service (Royal Cornwall Hospital Trust Facing) 1. Aim/Purpose of this Guideline The aim of this document to inform clinicians
More informationCLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN CANCER PATIENTS 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR MANAGEMENT OF NEUTROPENIC SEPSIS IN CANCER PATIENTS 1. Aim/Purpose of this Guideline 1.1. Systemic cancer treatments and immunological therapies can suppress the ability of the bone
More informationCLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING
CLINICAL PROTOCOL FOR X-RAYS AND CLINICAL IMAGING RATIONALE The aim of this Protocol is to provide guidance and good practice recommendations for health care professionals involved in clinical imaging
More informationCLINICAL GUIDELINE FOR THE EMERGENCY DEFILL OF AN ADJUSTABLE GASTRIC BAND
CLINICAL GUIDELINE FOR THE EMERGENCY DEFILL OF AN ADJUSTABLE GASTRIC BAND 1. Aim/Purpose of this Guideline The aim of this guideline to enable the effective care of patients needing emergency defill of
More informationCLINICAL GUIDELINE FOR MANAGEMENTS OF PATIENTS TAKING ANTICOAGULANTS IN ENDOSCOPY 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR MANAGEMENTS OF PATIENTS TAKING ANTICOAGULANTS IN ENDOSCOPY 1. Aim/Purpose of this Guideline 1.1. The purpose of this guideline is to assist decision making of whether anticoagulants
More informationClinical Guideline For The Use of Rectus Sheath Catheters For The Management of Pain Following Laparotomy. 1. Aim/Purpose of this Guideline
Clinical Guideline For The Use of Rectus Sheath Catheters For The Management of Pain Following Laparotomy. 1. Aim/Purpose of this Guideline 1.1. Nursing guidelines for the use of rectus sheath catheters
More informationUnder Review. Policy for Self Administration of medicines (SAM) by Competent Patients. Document Title. Date Issued/Approved: 18 th October 2013
POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department
More informationMANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS
MANAGEMENT OF POLICIES, PROCEDURES AND OTHER WRITTEN CONTROL DOCUMENTS Document Reference No: Version No: 6 PtHB / CP 012 Issue Date: April 2015 Review Date: January 2018 Expiry Date: April 2018 Author:
More informationAseptic Non Touch Technique (ANTT) Policy
Aseptic Non Touch Technique (ANTT) Policy V3 12 th May 2015 Page 1 of 19 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope... 3 4. Definitions / Glossary... 4 5.
More informationINTEGRATED GOVERNANCE FRAMEWORK
INTEGRATED GOVERNANCE FRAMEWORK V1.0 23 Jul 14 Table of Contents 1. INTRODUCTION... 3 2. STRATEGIC OBJECTIVES... 4 3. SCOPE OF THE INTEGRATED GOVERNANCE FRAMEWORK... 4 3.1 Definitions of Governance...
More informationHow To Write A Radiology Referral Policy At Canterbury Hospital
Contents Policy... 2 Purpose... 2 Scope/Audience... 3 Staff Groups... 3 Definitions... 3 Associated documents... 3 Equipment... 3 Policy details... 4 Background: Application of radiation to patients for
More informationPRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
PRESEPTAL AND ORBITAL CELLULITIS IN CHILDREN- CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. This guideline applies to medical and nursing staff caring for a child with Preseptal and Orbital
More informationCLINICAL GUIDELINE FOR THE MANAGEMENT OF HIGH BLOOD GLUCOSE LEVELS AND SICK DAYS ON AN INSULIN PUMP. 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR THE MANAGEMENT OF HIGH BLOOD GLUCOSE LEVELS AND SICK DAYS ON AN INSULIN PUMP. 1. Aim/Purpose of this Guideline 1.1. The purpose of this guideline is to give clear information and
More informationPHARMACISTS AMENDMENTS TO PRESCRIPTIONS
PHARMACISTS AMENDMENTS TO PRESCRIPTIONS May 2016 Version 2.3 Table of Contents 1. Introduction... 3 2. Purpose of this Policy... 3 3. Scope... 3 4. Definitions/Glossary... 3 5. Ownership and Responsibilities...
More informationDocument Title: Trust Approval and Research Governance
Document Title: Trust Approval and Research Governance Document Number: SOP034 Staff involved in development: Job titles only Document author/owner: Directorate: Department: For use by: RM&G Manager, R&D
More informationPROTOCOL FOR DUAL DIAGNOSIS WORKING
PROTOCOL FOR DUAL DIAGNOSIS WORKING Protocol Details NHFT document reference CLPr021 Version Version 2 March 2015 Date Ratified 19.03.15 Ratified by Trust Protocol Board Implementation Date 20.03.15 Responsible
More informationFINANCIAL POLICY PAYMENT FOR SUPPLIER INVOICES
FINANCIAL POLICY PAYMENT FOR SUPPLIER INVOICES Version 1.0 Important: This document can only be considered valid when viewed on the CCG s intranet/y: Drive. If this document has been printed or saved to
More informationCLINICAL GUIDELINE FOR THE MANAGEMENT OF OPIATE DEPENDENT PATIENTS AT RCHT 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR THE MANAGEMENT OF OPIATE DEPENDENT PATIENTS AT RCHT 1. Aim/Purpose of this Guideline 1.1. These guidelines are aimed at Medical Staff at RCHT treating patients admitted that are
More informationCouncil meeting, 31 March 2011. Equality Act 2010. Executive summary and recommendations
Council meeting, 31 March 2011 Equality Act 2010 Executive summary and recommendations Introduction 1. The Equality Act 2010 (the 2010 Act) will consolidate into a single Act a range of existing equalities-based
More informationCCG: IG06: Records Management Policy and Strategy
Corporate CCG: IG06: Records Management Policy and Strategy Version Number Date Issued Review Date V3 08/01/2016 01/01/2018 Prepared By: Consultation Process: Senior Governance Manager, NECS CCG Head of
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Occupational Health Records Management and Retention Operational Policy
The Newcastle upon Tyne Hospitals NHS Foundation Trust Occupational Health Records Management and Retention Operational Policy Version No. 1.0 Effective From: 9 October 2013 Expiry Date: 30 September 2016
More informationR&D Administration Manager. Research and Development. Research and Development
Document Title: Document Number: Patient Recruitment SOP031 Staff involved in development: Job titles only Document author/owner: Directorate: Department: For use by: RM&G Manager, R&D Administration Manager,
More informationInitial Equality Impact Assessment
Initial Equality Impact Assessment Department Service Area Date 20/10/11 This Initial EqIA will help you to analyse equality in the context of your policy, practice or function. The assessment is a useful
More informationPatient and Service User Feedback Policy (Compliments, Concerns and Complaints) V1.2
(Compliments, Concerns and Complaints) V1.2 17 December 2014 Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure... 3 3. Scope... 3 4. Definitions / Glossary... 3 5. Ownership and Responsibilities...
More informationMedical Device & Equipment Management Policy
29/07/2014 V2.0 Page 1 of 23 Table of Contents 1. Introduction... 4 2. Purpose of this Policy... 4 3. Scope... 4 4. Definitions / Glossary... 5 5. Ownership and Responsibilities... 6 5.1. Role of the Trust
More informationType of change. V02 Review Feb 13. V02.1 Update Jun 14 Section 6 NPSAS Alerts
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Medical Director Tony Gray Head of Safety and Patient Experience
More informationSummary of the role and operation of NHS Research Management Offices in England
Summary of the role and operation of NHS Research Management Offices in England The purpose of this document is to clearly explain, at the operational level, the activities undertaken by NHS R&D Offices
More informationRCHT Dementia Care Policy V1.0
RCHT Dementia Care Policy V1.0 April 2012 Table of Contents 1. Introduction...3 2. Purpose of this Policy...3 3. Scope...3 4. Definitions / Glossary...3 5. Ownership and Responsibilities...3 6. Standards
More informationINSERTION OF UMBILICAL LINES ARTERIAL (UAC) and VENOUS (UVC) - NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
INSERTION OF UMBILICAL LINES ARTERIAL (UAC) and VENOUS (UVC) - NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline This guideline applies to all staff undertaking the procedure of umbilical line
More informationCLINICAL GUIDELINE FOR VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC)
CLINICAL GUIDELINE FOR VAGINAL BIRTH AFTER CAESAREAN SECTION (VBAC) 1. Aim/Purpose of this Guideline 1.1. Due to a rise in the caesarean section rate there are increasing numbers of pregnant women who
More informationSafety Alerts Management Policy
Safety Alerts Management Policy Version Number 1.1 Version Date February 2014 Policy Owner Author First approval or date last reviewed Staff/Groups Consulted Director of Nursing and Clinical Governance
More informationTRANSPORT INCUBATOR AND VENTILATOR - NEONATAL CLINICAL GUIDELINE.
TRANSPORT INCUBATOR AND VENTILATOR - NEONATAL CLINICAL GUIDELINE. 1. Aim/Purpose of this Guideline 1.1. This guideline identifies the key equipment and testing requirements needed to ensure that the Neonatal
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust
The Newcastle upon Tyne Hospitals NHS Foundation Trust Procedure for Joint Management of Complaints and Safeguarding Concerns within the Newcastle upon Tyne Hospitals NHS Foundation Trust Version No.:
More informationPolicy for Prevention and Management of Falls in Hospital, and the Safe Use of Bedrails with Adult Patients V4.3
Policy for Prevention and Management of Falls in Hospital, and the Safe Use of Bedrails with Adult Patients V4.3 August 2015 Table of Contents 1. Introduction... 3 2. Purpose of this Policy... 3 3. Scope...
More informationRecord Management Policy
Record Management Policy Author: Kate Ayres, Governance Facilitator Owner: Fiona Jamieson, Assistant Director of Healthcare Governance Publisher: Compliance Unit Date of first issue: March 2006 Version:
More informationCLINICAL GUIDELINE FOR THE NEONATAL MANAGEMENT OF INFANTS BORN TO MOTHERS WITH THYROID DISEASE 1. Aim/Purpose of this Guideline
CLINICAL GUIDELINE FOR THE NEONATAL MANAGEMENT OF INFANTS BORN TO MOTHERS WITH THYROID DISEASE 1. Aim/Purpose of this Guideline 1.1. This guideline applies to Neonatal/Paediatric and Midwifery/Obstetric
More informationSubject Access Request Policy
Trust Policy Subject Access Request Policy Department / Service: Corporate Originator: Company Secretary Accountable Director: Director of Nursing Approved by: Information Governance Steering Group Trust
More informationRadiology Department. Local Procedure
Title: Radiology Department Local Procedure Procedure for requesting imaging procedures and sending out imaging reports Reference: Rad - 001 Author: Yvonne Shanks Date ratified: TBC Ratified by: Radiology
More informationThe reaction is termed anaphylaxis if there are life-threatening features such as respiratory difficulties and/or hypotension.
HYPERSENSITIVITY AND ANAPHYLACTIC REACTIONS DURING AND AFTER TREATMENT WITH CHEMOTHERAPY- CLINICAL GUIDELINE FOR RECOGNITION AND TREATMENT. 1. Aim/Purpose of this Guideline 1.1. The aim of this document
More informationProcedure No. 1.41 Portland College Single Equality Scheme
Introduction Portland College recognises the requirements under current legislation to have due regard to the general equality duty. 1.0 Context 1.1 Portland College supports equality of opportunity, promotion
More informationWho can benefit from charities?
1 of 8 A summary of how to avoid discrimination under the Equality Act 2010 when defining who can benefit from a charity A. About the Equality Act and the charities exemption A1. Introduction All charities
More informationThe policy applies to all members of staff employed within the Trust who are involved in any aspect of alert dissemination, action, and /or review.
The Newcastle upon Tyne Hospitals NHS Foundation Trust Central Alert System (CAS) Policy and Procedure Version No.: 4.2 Effective From: 26 th May 2015 Expiry Date: 26 th May 2018 Date Ratified: 11 th May
More informationEquality and Human Rights Impact Assessment (EqHRIA) Standard Operating Procedure
Equality and Human Rights Impact Assessment (EqHRIA) Standard Operating Procedure Notice: This document has been made available through the Police Service of Scotland Freedom of Information Publication
More informationADMINISTRATION OF VITAMIN K NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
ADMINISTRATION OF VITAMIN K NEONATAL CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. This guideline applies to all staff responsible for the administration of Vitamin K (Phytomenodium) to newborn
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Employment Policies and Procedures
The Newcastle upon Tyne Hospitals NHS Foundation Trust Employment Policies and Procedures Mobile Telephone and Telephone Expenses Reimbursement Policy Version No.: 1.0 Effective Date: 3 January 2013 Expiry
More informationEQUALITY IMPACT ASSESSMENT TEMPLATE - TRAFFORD COUNCIL
A. Summary Details EQUALITY IMPACT ASSESSMENT TEMPLATE - TRAFFORD COUNCIL 1 Title of EIA: To remodel building based day services 2 Person responsible for the assessment: Christine Warner 3 Contact details:
More informationCLINICAL PROCEDURE FOR THE SAFE REMOVAL OF FEMORAL ARTERIAL SHEATHS USING A DIGITAL APPROACH 1. Aim/Purpose of this Guideline
CLINICAL PROCEDURE FOR THE SAFE REMOVAL OF FEMORAL ARTERIAL SHEATHS USING A DIGITAL APPROACH 1. Aim/Purpose of this Guideline 1.1. To aide registered nurses in the safe removal of arterial femoral sheaths
More informationInspection report. Inspection of compliance with the Ionising Radiation (Medical Exposure) Regulations 2000
Inspection report Inspection of compliance with the Ionising Radiation (Medical Exposure) Regulations 2000 Organisation Site inspected Date of inspection Date of publication County Durham and Darlington
More informationSMALL FOR GESTATIONAL AGE FETUS - CLINICAL GUIDELINE FOR INVESTIGATION AND MANAGEMENT 1. Aim/Purpose of this Guideline
SMALL FOR GESTATIONAL AGE FETUS - CLINICAL GUIDELINE FOR INVESTIGATION AND MANAGEMENT 1. Aim/Purpose of this Guideline 1.1. To identify and optimally manage small and growth restricted fetuses. 2. The
More informationRECORDS MANAGEMENT POLICY
RECORDS MANAGEMENT POLICY October 2015 1 Subject and version number of document: Serial Number: Records Management Policy COR/010/V2.00 Operative date: October 2015 Author: CCG Owner: Links to Other Policies:
More informationEQUALITY AND DIVERSITY POLICY AND PROCEDURE
EQUALITY AND DIVERSITY POLICY AND PROCEDURE TABLE OF CONTENTS PAGE NUMBER : Corporate Statement 2 Forms of Discriminations 2 Harassment and Bullying 3 Policy Objectives 3 Policy Implementation 4 Commitment
More informationRECORD KEEPING IN HEALTHCARE RECORDS POLICY
RECORD KEEPING IN HEALTHCARE RECORDS POLICY Version 6.0 Key Points The Policy provides a framework for the quality of the clinical record facilitates high quality, safe patient care and that subsequently
More informationEquality Impact Assessment Form
Equality Impact Assessment Form November 2014 Introduction The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due
More informationColchester Borough Council. Equality Impact Assessment Form - An Analysis of the Effects on Equality. Section 1: Initial Equality Impact Assessment
Colchester Borough Council Equality Assessment Form - An Analysis of the Effects on Equality Section 1: Initial Equality Assessment Name of policy to be assessed: Internal Communications Strategy 2015
More informationCommissioning Policy: Implementation and funding of NICE guidance. April 2013. Reference : NHSCB/CP/05
Commissioning Policy: Implementation and funding of NICE guidance April 2013 Reference : NHSCB/CP/05 NHS Commissioning Board Commissioning Policy: Implementation and funding of guidance produced by the
More informationTreatment Escalation Plan & Resuscitation Decision Record. (in relation to the adult patient over 18 years) V4.0
Treatment Escalation Plan & Resuscitation Decision Record (in relation to the adult patient over 18 years) V4.0 1 st June 2015 Table of Contents 1. Introduction... 3 2. Purpose of this Policy/Procedure...
More informationIntellectual Property Management Policy
Intellectual Property Management Policy Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke Ken Lawrie/Karen Robinson Business Planning Group Date of draft
More informationANTENATAL BOOKING, ANTENATAL CARE AND INFORMATION - CLINICAL GUIDELINE
ANTENATAL BOOKING, ANTENATAL CARE AND INFORMATION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline This guideline gives guidance to midwives on: how to book a pregnant woman, instigate the appropriate
More informationEQUALITY IMPACT ASSESSMENT - TRAFFORD COUNCIL
EQUALITY IMPACT ASSESSMENT - TRAFFORD COUNCIL A. Summary Details 1 Title of EIA: Introduction of Credit Card Charges 2 Person responsible for the assessment: Dave Muggeridge 3 Contact details: 912 4534
More information3 Aims. 4 Duties (Roles and responsibilities)
The Newcastle upon Tyne Hospitals NHS Foundation Trust Centralised Room Booking Policy Version No.: 3.1 Effective From: 31 March 2015 Expiry Date: 31 March 2018 Date Ratified: 3 March 2015 Ratified By:
More informationSubject Access Request (SAR) Procedure
Subject Access Request (SAR) Procedure East and North Hertfordshire Clinical Commissioning Group Page 1 of 16 DOCUMENT CONTROL SHEET Document Owner: Chief Finance Officer Document Author(s): Anne Ephgrave
More informationRecords Management Policy
Records Management Policy Document information Document type: Operational Policy Document title: Records Management Policy Document date: November 2014 Author: NHS South Commissioning Support Unit, Information
More informationPolicy: Accessing Legal Advice
Policy: Accessing Legal Advice Executive or Associate Director lead Policy author/ lead Feedback on implementation to Rosie McHugh Wendy Hedland Wendy Hedland Date of draft April 2014 Dates of consultation
More informationSUBJECT ACCESS REQUEST PROCEDURE
SUBJECT ACCESS REQUEST PROCEDURE Document History Document Reference: Document Purpose: IG31 This procedure sets out the responsibility for staff when receiving requests for information provided under
More informationDOCUMENT CONTROL PAGE
DOCUMENT CONTROL PAGE Title: Preceptorship Policy Title Version: Reference Number: Supersedes Supersedes: All previous preceptorship prior to this date Significant Changes: Originator or modifier Ratification
More informationGENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline
GENERAL ANAESTHESIA FOR CAESAREAN SECTION - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 1.1. General anaesthesia for caesarean section carries considerable risk and is frequently performed out
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Medical Equipment Library Access to Service Procedure
The Newcastle upon Tyne Hospitals NHS Foundation Trust Medical Equipment Library Access to Service Procedure Version No.: 5.1 Effective From: 28 November 2013 Expiry Date: 28 November 2016 Date Ratified:
More informationThere are several tangible benefits in conducting equality analysis prior to making policy decisions, including:
EQUALITY ANALYSIS FORM Introduction CLCH has a legal requirement under the Equality Act to have due regard to eliminate discrimination. It is necessary to analysis the consequences of a policy, strategy,
More informationTHE EQUALITY ACT 2010
THE EQUALITY ACT 2010 October 1st 2010 saw many of the provisions attained within the Equality Act, which gained Royal Assent on the 8th April 2010, come into force. The following summary has been put
More informationHow To Protect Your Personal Information At A College
Data Protection Policy Policy Details Produced by Assistant Principal Information Systems Date produced Approved by Senior Leadership Team (SLT) Date approved July 2011 Linked Policies and Freedom of Information
More informationInformation Governance Policy
Author: Susan Hall, Information Governance Manager Owner: Fiona Jamieson, Assistant Director of Healthcare Governance Publisher: Compliance Unit Date of first issue: February 2005 Version: 5 Date of version
More informationRD SOP17 Research data management and security
RD SOP17 Research data management and security Version Number: V2 Name of originator/author: Dr Andy Mee, R&I Manager Name of responsible committee: R&I Committee Name of executive lead: Medical Director
More informationInformation Communication and Technology Management. Framework
Information Communication and Technology Management Framework Author(s) Andrew Thomas Version 1.0 Version Date 24 September 2013 Implementation/approval Date 25 September 2013 Review Date September 2014
More informationOVERVIEW OF THE EQUALITY ACT 2010
OVERVIEW OF THE EQUALITY ACT 2010 1. Context A new Equality Act came into force on 1 October 2010. The Equality Act brings together over 116 separate pieces of legislation into one single Act. Combined,
More informationPROTOCOL TO APPLY FOR AND SUBSEQUENTLY USE REMOTE ACCESS SOFTWARE. UHB 007 Version No: UHB 1. Data Protection Policy, IT Security Policy,
PROTOCOL TO APPLY FOR AND SUBSEQUENTLY USE REMOTE ACCESS SOFTWARE Reference No: UHB 007 Version No: UHB 1 Previous Trust / LHB Ref No: T/208 Documents to read alongside this Policy, Procedure etc (delete
More informationBUSINESS CONTINUITY MANAGEMENT POLICY
This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version BUSINESS CONTINUITY MANAGEMENT POLICY DOCUMENT CONTROL Type of Document Document Title
More informationComplaints Policy. Complaints Policy. Page 1
Complaints Policy Page 1 Complaints Policy Policy ref no: CCG 006/14 Author (inc job Kat Tucker Complaints & FOI Manager title) Date Approved 25 November 2014 Approved by CCG Governing Body Date of next
More information