1. Please provide all strategies relating to health records (electronic or paper health records) at your Trust – The Trust is primarily a ‘paper-based’ health records Trust. We are developing a medium-term plan to move to electronic records.

2. Please provide all policies relating to health records (electronic or paper health records) at your Trust – Please find the ‘Healthcare Records Policy’ attached below.

Healthcare Records Policy

 

3. In relation to the implementation of EPR, Clinical EDMS at your Trust, please provide:

a. Implementation plans – The Trust is currently in the process of procuring an EPR. Implementation plans are yet to be developed.

b. Project plans – Project plans are yet to be developed.

c. Project issue/risk logs – These are currently being formulated as part of the writing of the Full Business Case.

4. In relation to the transition from paper to digital health records at your Trust, please provide:

a. Any paper to digital transition plans – as Question 3.

b. Benefit realisation documents – These are currently being formulated as part of the writing of the Full Business Case.

 

Please note that, for the below questions, the Trust does not hold all the documents listed in your request. Under each question, we have specified the documents we do hold, if any.

 

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

There have not been any paperless/paperlite outpatient consultations at the Trust.

 

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

Please find attached below the Standard Operating Procedures (SOP) for the Runner Team Waiting List Prep and Waiting List Runner.

 

SOP – Runner Team Waiting List Prep

 

SOP – Runner Team Waiting List Runner

 

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

Please find attached above the Standard Operating Procedures (SOP) for the Runner Team Waiting List Prep and Waiting List Runner.

 

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

Please find attached below the Maternity Records Policy and SOP for Clinic Prep – Raise a New Medical Record.

 

Maternity Records Policy

 

Clinic Prep – Raise a New Medical Record

 

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

There is no Trust-wide SOP for loose filing. Each area is responsible for managing its own filing.

 

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

Please find attached the Missing Medical Records SOP and Creating a Temporary Medical Record SOP.

 

Missing Medical Records SOP

 

Creating a Temp Record SOP

 

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

This is not applicable to the Trust.

 

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

The paper records for community and acute are maintained independently.

 

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

Please find attached the relevant extract from the Trust’s Clinical Coding Policy and Procedures document and the SOPS for Patient transfers to Milford or Haslemere Hospital and Patient Discharges. 

 

Clinical Coding P&P – extract

 

SOP- Patient Discharges

 

SOP – Patient transfers to Milford or Haslemere Hospital

 

 

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

This is not applicable to the Trust.

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