Module 1 Trainer Handbook by t99KAB

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									Certificate of Technical Competence

         Operational Level




        Trainer’s Handbook

         [Add NHS Board]
Table of Contents

1.      Background ................................................................................................................................. 4
     1.1         What are Certificates of Technical Competence? ......................................................... 5
     1.2         What are the Benefits? ...................................................................................................... 5
     1.3         Getting Started .................................................................................................................... 6
     1.4         Portfolio ................................................................................................................................ 7
     1.5         Assessment ......................................................................................................................... 8

2.      Introduction ................................................................................................................................. 8
     2.1         Module Sessions................................................................................................................. 8

Module 1................................................................................................................................................. 9

Records Management......................................................................................................................... 9

3.      Module 1 - Records Management .......................................................................................... 9
     3.1         Function of the Health Records Service .......................................................................... 9

4.      Health Record ............................................................................................................................. 9
     4.1         What is a health record ...................................................................................................... 9
     4.2         What is patient identifiable information? ....................................................................... 10
     4.3         What is a corporate record .............................................................................................. 10
     4.4         What is an electronic patient record ............................................................................... 10
     4.5         Types of health records ................................................................................................... 13
     4.6         Types of corporate records ............................................................................................. 13
     4.7         What is the CHI number .................................................................................................. 13
     4.8         What is the Caserecord number ..................................................................................... 13

5.      Master Patient Index and Patient Registration ................................................................. 13
     5.1         Procedure for searching the MPI .................................................................................... 14
     5.2         Patient Registration .......................................................................................................... 14
     5.3         Creation of new record/file .............................................................................................. 15
     5.4         Patient/Record identification labels ................................................................................ 15

6.      Structure and Architecture of Health Records ................................................................. 15

The clinical record should be structured .................................................................................... 15

7.      Trainer Support Material – Module 1 ................................................................................... 18

8.      Session 1– Tasks ..................................................................................................................... 19

9.      Updating Records, Maintaining Patient Demographics ................................................. 21
     9.1         Recording and Updating of Patient Address Details ................................................... 21
     9.2         Recording of Ethnic Origin .............................................................................................. 22
     9.3         Overseas Visitor Status ................................................................................................... 22
     9.4         Notification and recording of death ................................................................................ 22
10.          Hazards and Alerts .............................................................................................................. 23

11.     Caserecord Tracking ............................................................................................................... 23

12.          Library Function/Electronic Patient Record System .................................................. 24
    12.1         Health Records Library .................................................................................................... 25
    12.2         Library Caserecord Maintenance ................................................................................... 25
    12.3         Checklist - Locating a missing record ........................................................................... 26
    12.4         Checklist – Merging Duplicate Records ........................................................................ 27

13.          Filing Systems...................................................................................................................... 28

14.          Storage Systems ................................................................................................................. 29

15.    Secure Transportation of Records and Business and Personal Health
Information .......................................................................................................................................... 30
    15.1         Transportation Packaging Methods ............................................................................... 30
    15.2         Privacy Markings............................................................................................................... 31
    15.3         Internal mail / transportation............................................................................................ 31
    15.4         External mail / transportation .......................................................................................... 32
    15.5         Transportation in vehicles................................................................................................ 32

16.          Retention and Destruction ................................................................................................ 32

17.          Trainers support material –Part 2 ................................................................................... 34

18.          Session 2 - Tasks ................................................................................................................ 35
Certificate of Technical Competence -Operational Level

1.     Background

It is estimated that there are in excess of 3600 clerical and supervisory staff working
across NHS Boards in Scotland who provide core Health Records Services to
patients and clinical staff in a variety of care settings. These staff provide a pivotal
role in Holding, Obtaining, Recording, Using and Sharing (HORUS) patient data and
are often the first point of contact with patients, public, health care providers and
other organisations.

NHS Boards provide induction and training at corporate and departmental level,
however this is generally not customised to meet the needs of Health Records
Services staff. As a result a number of NHS Boards have participated in the
development of a training course along with a standard set of training materials
which can be used by Health Records staff to gain a greater depth of knowledge in
their job role. The course is primarily focussed at staff in AfC Band 2 but is also
applicable to staff in bands 3 and 4.

IHRIM’s Certificates of Technical Competence (CTC) provide a framework for
learning enabling members of staff (those providing direct frontline operational
services) to demonstrate their competence by providing evidence of their knowledge
and skills to do their jobs.

NHS Scotland has worked with six NHS Boards and IHRIM to modify the existing
IHRIM syllabus to meet NHS Scotland needs. Training material, candidate work
books, trainer manuals and presentations have been developed to support
candidates undertaking the course. These will eventually be hosted electronically on
the NHS Education Scotland Admin and Clerical portal. This syllabus has been
endorsed by IHRIM`s education committee but remains the property of IHRIM.
IHRIM have responsibility to review this annually and to update as appropriate to
meet legislation, modernisation agenda etc.

In these days of change with an increasing focus on maximising business efficiency
in the NHS, the need for health records staff to have appropriate knowledge and
skills; taking cognisance of the future agenda for transforming services is critical.
Many health records staff provide front line operational services and have in depth
knowledge of the intricacies of the various patient pathways and the ‘handoffs’ that
reduce efficiency in the system. Health Records staff can therefore provide a
valuable contribution to service improvement and the deployment of electronic
systems to manage patient care records.

Staff development and training is therefore key to succession planning if you are
able to successfully contribute to the national agenda in these times of decreasing
financial budgets.




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1.1       What are Certificates of Technical Competence?

Certificates of Technical Competence offer a framework for learning enabling
members of staff in AfC Bands 2 to 4 (those providing direct frontline operational
services) to demonstrate their competence by providing evidence of their knowledge
and skills to do their jobs. Competence is demonstrated in a number of ways:
    A work place assessment of the member of staff by a trained Assessor
           o Entering data
           o Receiving patients at a reception desk
           o Preparation of records for outpatient clinics
           o Providing information requested under data subject access

         Provision of a structured portfolio with evidence supporting the criteria
             o Use of reflective statements – These are statements written in the staff
                 members own words describing the content of a policy or document
                 such as the NHS Scotland Code of Practice on Confidentiality, or
                 describing the steps undertaken to complete a task or procedure such
                 as Searching the MPI, or checking in a patient to a clinic. The
                 statement should be written in the staff members own words and
                 include reference to local systems and procedures. It should not merely
                 be lifted from the study notes contained within the work book. There
                 are templates for constructing these contained in the candidate
                 workbook.
             o An up-to-date CV
             o Current Job Description
             o Record of training
         A question and answer interview
             o Questions specific to the criteria not picked up through
                 observation/portfolio

Certificates of Technical Competence (CTC) have been written to underpin the NHS
Knowledge and Skills Framework (KSF). The CTC is designed to support effective
learning and development of individuals and teams and will provide evidence for
your appraisal. It will also assure your supervisor/manager that you are meeting the
majority of the KSF outline when they discuss gateway review, performance and
personal development planning. The outcome and recommendations from the
assessment will form the basis of your Personal Development Plan throughout the
year as well as identify departmental training needs.


1.2       What are the Benefits?

Generally this qualification provides assurance to your NHS organisation that you
are working within a robust education framework which meets the requirements of:
    Records Management and the development of electronic patient records
    Understanding the Patient Journey including national imperatives such as 18
      Week Referral To Treatment Standard and electronic management of patients
      progression through the pathway
    Information Assurance
    Communication
    Health and Safety

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         Service Improvement

 The Syllabus has been structured to meet the following:
    Information Governance in NHS Scotland: A Competency Framework
    KSF Gateway Review
    PDP Reviews
          o Individual’s responsibilities around personal development
    Mandatory Training
    Service Improvement
          o Patient facing skills
          o Clinical record keeping practices
          o Preservation of the corporate memory of the organisation
          o Valuing equality and diversity
          o Incident and risk reporting
          o How to improve service delivery
    Legislation
          o Confidentiality and information governance requirements
          o Managing records effectively
          o Health and Safety – staff, patients and visitors
    National Initiatives
          o Timely and accurate data entry
          o Data quality standards

Experience has shown that this qualification:
    formally recognises competence
    raises profile and professional standing
    builds confidence
    consolidates learning
    actively encourages working within teams
    builds morale and motivation

1.3       Getting Started

As candidates progress through their CTC qualification you will find that the majority
of their learning and assessment will be through developing and building up of their
skills and knowledge of systems, processes and procedures and local (and national )
policies. They will need to demonstrate to the assessor that they have a sound
knowledge of each element within the five modules and that they can practically
demonstrate this within their workplace.

The course usually runs over 6 consecutive weeks.

When candidates enrol on the course they will be provided with a work book
covering the five study modules:

         Records Management Sessions 1&2
         Patient Journey
         Information Assurance
         Communication and Relationships
         Health and Safety, Personal Development and Service Improvement

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In order to complete each module they will be required to do five things:

      1. Personal preparation time to read and research the module content.
      2. Review tasks and access reference material to support their learning and
         understanding of these.
      3. Attend a training session with a designated trainer who will cover the module
         content. These sessions tend to be fairly informal and focus on discussion of
         topics enabling them to explore the subject and consider the implications for
         their job role.
      4. Write up what they found or learned using the task templates.
      5. Obtain samples of documents, policies or procedures to build their portfolio
         document throughout the duration of the course.


Experience has shown that it takes between 5 and 7 hours to prepare, complete
tasks and gather evidence for each of the five modules. The training session lasts
approximately one to two hours.

The following week you will sign off the tasks that they have completed to ensure
they are satisfactory.

During the course they will be required to build a portfolio including all course
material and evidence of their learning.

Throughout the course you will review their portfolio and generally revise the key
outcomes of the modules or address any areas where you feel they need further
support or guidance.


1.4      Portfolio

The portfolio is a record of all the evidence the candidate has collected which
support the assignments / tasks they have carried out and should contain

Front cover or title page
    Information about yourself
       - Personal profile
       - Work experience
       - Qualifications
       - Training
    Completed module Tasks – a              record of all information collected and
       completed reports

The portfolio template is available electronically.




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1.5    Assessment

When the candidate has completed all five modules and built their portfolio an
assessor (who is accredited by the Institute of Health Records and Information
Management) will arrange a convenient time to visit their work place to assess their
understanding of their job. The assessment typically last 45 mins to an hour and
involves three aspects:
   1. Review of the content of their portfolio
   2. Observing the candidate in their workplace demonstrating the job role that
       they normally undertake
   3. Probing and questioning to establish the candidates understanding of their job
       and the key aspects which they must understand to perform their role
       competently and effectively

Following this the assessor will write a short report summarising their observations
and opinion. This report will be submitted to the Institute of Health Records and
Information Management (awarding body) who will on the assessor’s
recommendation award your certificate.

Assessment will be undertaken according to the guidance provided by the Institute of
Health Records and Information Management (IHRIM) and in accordance with the
operational level Certificate of Technical Competence syllabus.


2.     Introduction

2.1    Module Sessions

As your candidates progress through their CTC qualification they will find that the
majority of their learning and understanding will be through developing and building
up skills and knowledge of systems, processes and procedures and local (and
national) policies. They will need to demonstrate to the assessor and to you, that
they have a sound knowledge for each element within the five modules and can
practically demonstrate this within their workplace.

The trainer handbook - will provide you with the subject matter for each module and
practical support such as Tasks for the candidate to complete prior to each session.
Also included are a list of suggested discussion prompts and scenarios which can be
used during your training session to help gauge your candidates level of knowledge
and understanding of each of the modules.         The handbook is flexible and you
should add your own prompts / scenarios as appropriate.

The presentation slide packs – will provide support for the delivery of each module.
They can be used at the beginning of a training session to provide an overview of the
module content or at the end, as a ‘check list’ to review what has been covered
during the session.

It should be noted that the slide pack for Module 1 depicts an overview of both
Modules 1 & 2 i.e. Records Management and The Patient Journey. The rationale
behind this was to demonstrate the ‘end to end’ process of the role of health records
staff throughout a patient’s journey of care. .


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Trainer Handbook
                                      Module 1

                             Records Management


3.     Module 1 - Records Management

3.1    Function of the Health Records Service

The Health Records Service is responsible for providing a high standard of Health
Records and administrative services to patients, clinicians and authorised external
agencies. The service is responsible for the maintenance, confidentiality and security
of all patient data both manual and electronic records in accordance with legal
requirements, standards, evidence based practice and professional work practice.

Within your NHS board there will be a number of referral pathways into your
department / service. These may be electronic or paper depending upon the referral
source and the systems used to create the referral document. The most common
include

GP referrals – these account for the largest percentage of referrals made to
secondary care health services. Within Scotland the SCI Gateway system is used to
electronically transmit referral documents and attachments from GP practices to
hospital and secondary case services. (These can also be received as paper
referrals)

Internal referrals – these are referrals which are generated within your NHS board
and are usually made from one health care professional to another. These referrals
can be either electronic or paper.

 3rd Party / Tertiary referrals - these referrals are made from one NHS board to
another NHS board and usually relate to cases where the patient requires specialist
investigation or treatment at a regional centre e.g oncology / neurological or renal
services. These referrals can be either electronic or paper.


4.     Health Record

4.1    What is a health record

A health record is a single record with a unique identifier, which is a composite of all
data on a given patient. It contains information relating to the physical or mental
health of an individual who can be identified from that information and which has
been recorded by, or on behalf of, a health professional, in connection with the care
of that individual. This may comprise
     text,
     sound,
     image
     and/or paper



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and must contain sufficient information to support the diagnosis, justify the treatment
and facilitate the on-going care of the patient to which it refers.

Scottish Government Records Management Code of Practice v 2.0

4.2       What is patient identifiable information?

Patient identifiable information is anything that identifies the person. It includes
things like:

         Patient demographic details: Name, Address, Full Post Code, Date of Birth;
         CHI ( Community Health Index Number) – contains the patients date of birth
          and a number to indicate their sex;
         Picture, photograph, video, audio tape or other image of the patient and
         Anything else that may be used to identify a patient directly or indirectly – for
          example, rare diseases, drug treatments or statistical analysis which have
          very small numbers within a population and may allow individuals to be
          identified

Use of a combination of the above demographic data items – that is, name, address,
postcode, date of birth and or CHI increases the risk of patient identification.
Therefore whenever patient listings are being extracted or printed it is good practice
to use the minimum amount of patient demographic data – for example, when a list
of records is to be retrieved for clinical audit, it is good practice to include only
caserecord or CHI number along with surname to reduce risk of identification of
individual patients

4.3       What is a corporate record

A record (other than a health record) that is of, or relating to an organisation’s
business activities covering all the functions, processes, activities and transactions of
the organisation and its employees.

4.4       What is an electronic patient record

An electronic patient record (EPR), also electronic personal health record (EPHR) or
electronic health record (EHR) is an evolving concept defined as a systematic
collection of electronic health information about individual patients. It is a record in
digital format that is capable of being shared across different health care settings, by
being embedded in network-connected enterprise-wide information systems such as
the Patient Management System (PMS). Such records may contain a whole range of
data in comprehensive form e.g. the entire record for a hospital or GP Practice or
in summary form where key items of data are collected from a number of different
systems and presented together.

Examples of a summary record are:

         Emergency Care Summary (ECS) which is constructed from data contained
          within GP IT systems and currently accessed with the patients consent when
          patients make contact with NHS 24 or attend hospital Accident and
          Emergency Departments.


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      Key Information Summary (KIS) which comprises of GP and secondary care
       health information and is used to manage the care of patients with long term
       conditions.

      Emergency Palliative Care Summary (ePCS) is a way of sharing important
       information about a patient’s palliative care. The ePCS contains information
       from the GP record – for example, information about medical condition and
       treatment, carer and about any wishes the patient may have about their
       treatment. It is updated regularly. An ePCS will only be made if the patient
       consents to this.

       NHS staff who need to give care and treatment when a GP surgery is closed
       can look at it. This includes doctors, nurses and receptionists in out-of-hours
       medical centres, staff at NHS 24, and NHS staff in hospital accident and
       emergency departments involved in the patients care.

Data held in electronic patient records includes patient demographics as well as
clinical history, medication, alerts and hazards, investigation results and radiology
images.

The introduction of EPR technology offers numerous and significant benefits:

     Stores and transfers patient information electronically and therefore has the
       potential to significantly reduce clinical errors and improve patient safety;
     Allows clinicians to communicate more quickly and accurately;
     Identifies relevant information more easily;
     Reduces duplication and waste and improves the efficiency of health services.

In some cases electronic patient record systems can also make clinical information
more accessible to patients allowing them to assume more control over their health
records and thereby become more active in management of their own health care.
Examples include the Scottish Renal System that enables patients to log in to their
renal record from home to view investigation results and clinical letters. A number of
other patient portal demonstrator pilots in NHS Scotland also allow patients to view
selected clinical data and book appointments or request prescriptions or advice.

In addition electronic health records can be used for a number of secondary
purposes (used for any purpose other than provision of direct patient care) for
example clinical audit, disease registers, cancer tracking and research provided that
the data is used in accordance with NHS Scotland Information Governance and
consent policies.

EPR is a potentially transformative technology which will bring about significant
change to the delivery of modern health care.

Alongside these new opportunities EPR systems also bring about new risks and
challenges, particularly to the privacy and safety of health information. Electronic
systems allow access to data from many locations and systems, increasing the
potential of a security breach. Access to specific aspects of the patient’s record
therefore require to be controlled on a strict need to know basis. This is known as
Role Based Access Control (RBAC) and is normally assigned to the staff member


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according to their job role or function. The staff member’s level of access to the
record is therefore limited to the data or documents that they require to perform their
job. In addition EPR systems audit all viewings, updates and creations within the
patients record against the staff member’s unique user profile thereby providing
evidence of every transaction that has taken place in respect of both the staff
member and the individual patients record.

Your NHS Board will have a Health Records Strategy which outlines the roadmap
from your current paper based health records systems towards electronic health
records and clinical portal systems to allow personal health information to be
accessed, viewed, created and shared electronically throughout all stages of the
patient’s journey.

Clinical portal technologies will allow clinicians to view defined information about
their patients in one place, even if the information is actually held in a number
of different clinical systems. Information is brought together at the time when it is
needed, in the form of a 'virtual' electronic patient record. The clinical portal itself is
not a single product. It is delivered by joining together a series of products and
services which work together to provide information for clinicians.

The roadmap to progress towards electronic patients records will vary according to
each NHS Board. The operational plan may include use of the new Scottish
Foundation Patient Management System as well as various clinical systems
currently in use in NHS Boards. As well as capturing clinical data directly via
electronic systems and eforms there may be a requirement to scan paper documents
or records which have been created retrospectively or prospectively using an
Electronic Document Management System (EDRMS).

Operational processes within Health Records departments will require to be
reviewed and re-designed in order to progress through the transition when there will
be a mixed economy of paper and electronic data through to the goal of all or most
data being generated and captured electronically. GP Practices use GP Information
Technology systems (GPIT) at practice level to record all clinical information for
patient encounters. The GPIT System coupled with document scanning for all paper
correspondence or reports which arrive at the practice from secondary care have
enabled practices in Scotland to become quite well advanced in development of
electronic health records. GP Practices also currently have the ability to
electronically transfer records of patients from one practice to another in Scotland
when a patient moves area and registers with another practice.




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4.5       Types of health records

         Personal health records (electronic or paper based, and concerning all
          specialties, including GP medical records);
         Records of private patients seen on NHS premises;
         Accident/Emergency, birth and all other registers;
         Theatre, minor operations and other related registers;
         X-ray and imaging reports, outputs and images;
         Photographs, slides and other images;
         Microform (i.e. microfiche/microfilm);
         Audio and video tapes, cassettes, CDROMS etc;
         Emails ;
         Records held on computer ; and
         Scanned documents held on document management systems.

4.6       Types of corporate records

         Administrative records ;
         Financial;
         Property, environment and health and safety;
         Human resource;
         Procurement and stores.

4.7       What is the CHI number

The CHI (Community Health Index) number is a unique identifier, allocated to each
patient at birth or first registration with a GP Practice in Scotland. It is a 10 character
code consisting of the 6 digit date of birth (DDMMYY), two digits, a ninth digit, which
is always even for females and odd for males, and an arithmetical check digit. It is a
key component in the implementation of an Electronic Patient Record in Scotland. It
is mandatory to record the CHI number on all clinical correspondence throughout
NHS Scotland. The only exception to this is when the patient is not resident in
Scotland.

4.8       What is the Caserecord number

The caserecord number is the reference number that is allocated to a patient’s
physical record folder. The number is usually automatically generated by the Patient
Administration/Management System each time a new patient is registered on the
MPI. It is primarily used to file the record. The format for the caserecord number is
not standardised throughout Scotland. You should familiarise yourself with the
various caserecord numbers used within your hospital, service or NHS Board


5.        Master Patient Index and Patient Registration

The Master Patient Index (MPI) is an alphabetical key to caserecords which are filed
numerically. The MPI can be held manually on a card index, or on computer within
the Patient Administration/Management System.


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The MPI contains all patient demographic data: surname, forename, date of birth,
sex, ethnicity, telephone number, address, post code, risks or hazards, special
needs, name and address of general practitioner, alternative address.

The MPI should be checked each time the patient is referred or makes contact with
the service to ensure that patient demographic data is kept up to date.

5.1    Procedure for searching the MPI

Patient demographic details to be entered in to search include – surname, forename,
date of birth, CHI Number, postcode, sex.

Steps to take for searching:

       1. Local search of PAS/PMS
       2. National search of CHI

5.2    Patient Registration

If a patient cannot be found on the MPI it may be necessary to create a new
registration in order to initiate a record of the patient’s referral, attendance or
admission. Prior to creating a new registration you must follow the approved
procedures for checking the MPI in your department / service. This ensures the
accuracy and integrity of data and prevents duplicate patient registrations being
created.

Within your department / service there will be procedures for registration of
unconscious or unknown patients.

Within your Patient Administration/Management System (PAS/PMS) there will be a
minimum dataset which is required in order to register a patient on the MPI. The
types of data items which are considered mandatory are listed below. You should
note that these may vary from hospital to hospital and are dependant upon the
configuration of the PAS/PMS system. This data is required to be recorded each
time a new patient registration is created so that the patient can be positively
identified on any subsequent referral or attendance at your hospital/service.

Minimum dataset includes:

Title, Surname, Forename, Sex, DOB, CHI, Caserecord Number, GP/Dental
Practitioner, Address, Postcode etc.

Process to be followed if DOB recorded on CHI Number does not match information
provided by patient.

Whenever the DOB provided in referral documents or by patients does not match
that contained in the CHI number, details should be personally verified by the
patient. Whenever the DOB in CHI is found to be erroneous this should be notified to
the appropriate Regional Primary Care Registration Department via the appropriate
notification form signed by the patient.
Note: The CHI number field should be left blank until the Primary Care Registration
Department have notified your department of the updated CHI number.

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5.3      Creation of new record/file

Whenever a new patient is registered on the MPI a new record file will be created to
store the patient’s clinical information. This traditionally has been a paper based file,
however progress is being made to move towards electronic patient records and
therefore files are now often created within Electronic Document Management or
Clinical Portal systems.

5.4      Patient/Record identification labels

Whenever a new patient is registered on the MPI and a new file is created a set of
patient identification labels are printed containing the patients demographic data
(Surname, Forename, DOB Address, Postcode, Sex, CHI, Caserecord Number etc)
These are used to identify any clinical or administrative documentation within the
record and for use of clinical staff when making laboratory or diagnostic requests.
Laboratory specimens are also normally identified by attaching a patient
identification label.

A set of caserecord identification labels are usually also printed to attach to the front
cover of the caserecord. These usually contain the patients surname and forename
along with the CHI and or Caserecord number. Where a computerised caserecord
tracking system is employed the caserecord filing number is usually bar-coded to
enable scanning in order to facilitate fast and efficient updating of the tracking
system each time the record moves location or is returned to the health records
library for filing.


6.       Structure and Architecture of Health Records

Each NHS Board, organisation or service will have a design of record folder and
clinical documentation which is suitable for delivery of clinical care.
You should familiarise yourself with the design and architecture of health records
which you use in your job.

The main requirements for recording of clinical data are listed below:

      The clinical record should be structured
       Entries should be made as soon as possible after the event, be dated, timed
         and signed.
       Have the name of entry author legibly printed against the signature
       Be legible and made in black ink
       There should be patient identification on each page
       Have any deletions or alterations countersigned
       Diagnostic test results should be signed before filing
       The record should be structured
       There should be a system for recording alerts
       There should be a system for identifying information supplied by a third party
       Use of standard abbreviations
       Clearly identify the patient


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      Every record entry should identify the most senior doctor present at the time
       the entry was made.
      There should be an entry in the record at least once every 24 hours for acute
       medical care, and at least twice a week for rehabilitative care.
      For acute medical admissions, the record entry should include information
       under the following headings:
       - Patient’s registered GP details
       - Admission details (administrative)
       - Reason for clinical encounter
       - Presenting problem/complaint
       - History of presenting problem
       - Current diagnoses
       - Allergies
       - Past illnesses
       - Procedures and investigations
       - Medications and diets
       - Social circumstances
       - Functional state
       - Family history
       - Systems review
       - Examination findings
       - Results of investigations
       - Overall assessment
       - Problem list
       - Management plan
       - Intended outcomes
       - Information given to patient
       - Follow-up arrangements
       - Discharge summary information should be validated by a senior clinician

Patients have a right to be fully involved in decisions about their care. Their
involvement should be documented in the caserecord.

The content of each record should comply with the clinical guidance provided by the
institutions including the Royal Colleges, Nursing and Midwifery Council, Health
Professions Council and the General Medical Council.

The above structure of contents applies to all health records regardless of the media
whether paper or electronic or both.




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7.     Trainer Support Material – Module 1

Trainers can use some /all of the support material provided below or add their own
as appropriate for their candidate groups.

TASKS

Prior to the start of each Module candidates should complete the Tasks showing in
their workbook and provide within their portfolio evidence of:
 Any required written communication
 Leaflets / policies etc
 Reflective statements

The tasks have been designed to support the trainees understanding of the various
topics / heading within each module. Trainers could use the TASKS to start each
training session, getting candidates to provide a recap of completed tasks.


Discussion Prompts

Discussion prompts can be used to instigate discussion during the training session.
These could be adhoc discussions directed at the whole class or set questions
passed out to individuals or discussed in small groups.

The prompts documented below are only a suggested list of prompts to use to
support the trainees understanding of the various topics / headings within the module
/syllabus. Trainers are encouraged to use or add their own discussion prompts as
they feel is appropriate to their candidate group.


Scenarios

Suggested scenarios have been included to support the trainees understanding of
the various topics / headings within the syllabus. These could be used in small
groups and feedback to the whole group during the training session. Trainers can
use these scenarios, or add their own scenarios as they feel is appropriate to their
own NHS board or candidate group.




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8.     Session 1– Tasks


Heading - Searching MPI / registration of new patients / maintaining patient
demographics

Searching the MPI - Draft a simple step by step guide explaining the order of search
and listing the patient demographic data items which you would use to positively
identify a patient on the MPI. eg Local PAS search - SCI search – National CHI
search ….

Trainer note – Candidate should explain each level of search and be able to list the
items of patient demographic data which they would include in the search criteria e.g
     Surname
     Forename
     DOB
     Sex etc

Registering a new patient – List the steps you would follow to register a new patient
on the MPI.

What mandatory patient demographic data is required before you can register a
patient on the MPI.

Creating a New Record - List the steps you would follow to create a new record paper
/ electronic or both.




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                   Module 1

                   Session 2




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9.        Updating Records, Maintaining Patient Demographics

It is important to check demographic details (Name, Address, DOB, Postcode,
Contact telephone, GP practice details etc) each time a patient is referred or
presents for care, for example referral to clinical service from GP, attendance at out-
patient clinic, attendance at Accid/Emergency or admission.

Checks can be made via a variety of methods:

         Checking details from referral letter or form
         Patient completing an out-patient clinic proforma prior to or during their
          attendance at hospital
         Confirming details personally with patient face to face or by telephone

9.1       Recording and Updating of Patient Address Details

Within each PAS/PMS system there will be options for recording of patient’s
permanent, temporary and or correspondence address. You should appraise
yourself with the policy for your own NHS Board. The following are general principles
to be considered whenever recording or updating address.

9.1.1     Patients

      a. The new address and postcode should be entered as permanent address.
         Some PAS/PMS systems will retain the old address under a previous address
         field for reference purposes.
      b. Beware that patient’s GP and Practice details may also change if the patient
         changes town or area. It is good practice to verify/check GP details at the
         same time as updating address.

9.1.2     Prisoners

      a. The last known home address should be entered as permanent address.
      b. The prison address should be entered as temporary and or correspondence
         address. Note correspondence is often addressed via the Prison Medical
         Centre or Nursing staff.
      c. Details of the Prison GP or Medical Officer should be entered in the GP
         Practice field.

9.1.3     Visitors

      a. Home address should be entered as permanent address.
      b. Holiday address along with valid dates should be entered as temporary
         address.
      c. Care should be taken to obtain full GP and Practice address details. These
         should be entered according to local NHS Board policy.

9.1.4     Students/ Boarding Schools

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      a. Term time address should be entered as permanent address.
      b. The parent’s home address should be entered as the temporary address.
      c. The student’s/pupil’s student term GP name and address should be entered in
         the GP Practice field.

All changes to patient demographic data should be made in the MPI and any other
dependant systems as well as the patient caserecord folder when it is being
prepared for the patients attendance at hospital. Patient identification labels with up
to date demographic details should be printed and great care should be taken to
remove all redundant labels from the file prior to the new labels being inserted. The
patient identification block or sheet within the record should be updated clearly in
accordance with local procedures.

9.2      Recording of Ethnic Origin

Whenever a new patient is registered on the MPI their ethnic origin should be
established and recorded in line with NHS Board policy.

9.3      Overseas Visitor Status

Whenever a patient attends as a new referral to a service or is admitted to hospital
their overseas visitor status should be recorded in accordance with NHS Board
policy to enable charging if the patient is found to be liable for NHS charges.

9.4      Notification and recording of death

Whenever a patient dies it is important that the Master Patient Index and any records
are updated.

If the death occurs within the hospital there is a statutory requirement to notify the
local registrar of deaths of the patients details, in order that the registrar can ensure
the death has been registered within the statutory period.

Within each NHS Board there are well defined processes for receiving death
notifications and actioning these. These come from a variety of sources, hospital
wards, GP’s, relatives and local/central registrars office. Depending on the source of
the notification it may be necessary to verify accuracy of the notification with the
patients General Practitioner or the Registrars Office prior to updating the MPI and
records system.

Prior to recording death details on the MPI it is important to check for any
outstanding referrals, patient transport requests, appointments and activity e.g.
Radiology requests etc. All such activity should be cancelled unless ordered in
connection with an autopsy.
It is also important to notify departmental record holders if departmental records exist
in the organisation so that these can be updated.




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10.       Hazards and Alerts

A hazard or alert is clinical or administrative information which should be immediately
drawn to the attention of staff whenever a patient intervention takes place.
Examples include:

         Suspected/Known drug allergies and sensitivities
         Sensory impairment
         Physical/ Learning Disability
         Advance statements/directives/living wills
         Hospital Acquired Infection – e.g. MRSA
         Mechanical/Electronic device in situ – e.g.Pacemaker
         Multi- Agency Public Protection Authority (MAPPA)

Hazards and alerts may be recorded on manual/computerised health records,
Patient Administration/Management systems and clinical systems.
Hazard and alerts need to be recorded in a clearly identified place in the patient’s
record or computerised system that is clearly seen by authorised staff, without being
visible to other members of the public.

Patient records will have a specific form or data field designed to record alerts.

Your NHS Board should have a policy in place to describe which users can record
alerts and advising of procedures to update alerts which become obsolete.


11.       Caserecord Tracking

Caserecord Tracking Systems are essential to record the movement of the record as
it progresses throughout the organisation. Tracking is essential to enable records to
be located and made available each time the patient presents for treatment and
consultation. The caserecord tracking system allows us to know at all times where
the caserecord is located. It provides a comprehensive history of the patient’s record
movements. All administrative/clinical staff have a personal responsibility and duty
of care for ensuring that caserecords are tracked each time they are moved to
another borrower. Failure to correctly track a caserecord can lead to a clinical risk to
the patient due to clinical information being unavailable.

Various systems can be used to track records ranging from common or personal
tracer cards to computerised chart tracking systems which are often an integral
module of the patient administration/management system.

Common tracer card – A4 paper reusable card, records patient hospital number,
name, location record is tracked out to and date.

Advantages: simple and easy to operate, cost effective, can be reused for other
patients.

Disadvantages: risk of loss, may not be legible, no comprehensive history of
caserecord movement, only records last movement, time consuming as the filing
area needs to be accessed every time to establish the current location of the record.

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Personal Tracer Card – Card stored within caserecord. Card is removed from
caserecord when it is retrieved, updated with location/date and inserted into filing
system.

Advantages: history of all caserecord movements, one card per patient.

Disadvantages:- costly, time consuming to use.

Library ticket – Ticket stored within caserecord. Card is removed from caserecord
when it is retrieved, updated with location/date and inserted into a separate filing
drawer/system.

Advantages: history of all caserecord movements, one card per patient.

Disadvantage: costly, time consuming to use.

Computer system - caserecord is tracked using Patient Administration/Management
system, all movements updated as they occur. Can be entered by keyboard or by
scanning bar code.

Advantages: ease of access anywhere in the hospital, comprehensive history of all
caserecord movements, secure full transaction log identifying which user has
updated system, less time consuming. Does not take up space in the filing room
(unlike tracer cards)

Disadvantages: users may not have access to Patient Administration/Management
system, unable to access caserecord if computer system goes down.


12.    Library Function/Electronic Patient Record System

Whenever a clinical record is held in paper format it will be administered by the
Health Records library function. Records are stored and filed using one or more of
the methods described later in this module.

This is a dedicated area which is used to store health records. Most NHS Boards will
operate a number of records libraries depending on the organisation and geography
of services.

Peripheral office accommodation and storage areas – records may be stored in a
number of offices and departments whilst in use. These offices should be subject to
the same security arrangements as the main library, with defined access processes
i.e. 24 hour access for emergency retrieval if records are required out with office
hours.

Electronic and scanned clinical records are held within SCI Store and/or bespoke
Electronic Document Records Management Systems (EDRMS) and either viewed
directly from EDRMS or via a Clinical Portal.



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12.1   Health Records Library

Current Records Library – Used to store records of patients who are currently or
have recently attended hospital or health care services.

Archive Records Library – Used to store records of patients who are not currently or
have not recently attended hospital or health care services.

Offsite storage – in some boards health records (current and archival) are stored
within offsite libraries. These may be managed in house or by specialist storage
companies on behalf of the NHS.

There are well defined procedures for the transfer and retrieval of records to and
from secondary and offsite storage facilities.


12.2   Library Caserecord Maintenance

Within your department there are procedures to maintain the patient’s folder and to
manage storage systems to ensure that caserecords can be made available
whenever required.
You should familiarise yourself with your department’s procedures for:
    Use of year of attendance notifications/labels
    Use of colour coding as an aid against misfiling
    Replacement of torn folders
    Splitting of ‘fat’ files
    Culling/weeding of records
    Transfer of records to archival facility
    Destruction of records

Despite the use of caserecord tracking systems there may be times that a patient’s
record cannot be found at the location it was last tracked to. This is almost always
due to staff either not updating the tracking system when a caserecord has moved or
not having paid attention to correct filing of the record when it has been returned to
the library. You should familiarise yourself with the process for checking for a
missing caserecord. The checklist below summarises the main activities to be
undertaken when a record cannot be located.




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12.3     Checklist - Locating a missing record


       Check that caserecord reference number is correct using MPI and ensure
       casenote is not a duplicate registration


       Check last location that the caserecord is tracked to, physically check location,
       borrowing department or office


       Check filing system shelf for possible misfile. Check filing system for wrong
       terminal digits, physically checking colour if colour coding system is in use


       Check previous location history and liaise with borrowers



       Check for any forthcoming appointments or waiting list entries as this may
       provide an insight into the possible current location of the caserecord


       Telephone general practitioner to ascertain if patient is attending any other
       hospital or service


       Liaise with clinical staff to ascertain if they have any information which would
       identify current location of caserecord


       Send electronic request to all system users


       If caserecord cannot be found, escalate to department supervisor/ manager,
       advise clinician and ascertain what action is to be taken e.g. obtaining copies of
       investigation reports and correspondence to enable consultation to take place

       Initiate temporary record filing all copies of relevant information and record
       details in missing record register to enable a regular check to be undertaken to
       locate record

       When record is found, physically merge contents of temporary record and
       record details of place and date found in the missing record register




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In cases when the MPI has not been thoroughly checked a second registration and
record may be created in error. You should familiarise yourself with the process for
merging of duplicate records. Whenever a duplicate record is suspected this should
be drawn to the attention of the health records management team. The checklist
over summarises the main activities to be undertaken when a merging duplicate
records.

12.4    Checklist – Merging Duplicate Records


       Identification of records and confirmation that both records relate to the same
       patient


       Checking and confirming correct patient demographic data



       Retrieving both records and inspecting contents



       Checking to see which systems patient is recorded on and deciding which
       number should be kept


       Destruction of obsolete patient identification labels, blank documentation and
       folders


       Production of an up to date set of patient identification labels for use in the
       merged record


       Physical merge of all patient documentation ensuring that each page bears the
       correct patient demographic data and reference number


       Merging of both MPI Records on the patient administration system



       Notification of change of hospital number to any third parties or departmental
       system managers


       Notification of change of hospital number to patient




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13.      Filing Systems

A number of filing systems may be used to file health records. The advantages and
disadvantages of each of these are detailed below:

Alphabetic

Advantages
   Does not need a Master Patient Index to access records
   Easy to use and requires minimum staff training

      Disadvantages
          Less secure and open to access by unauthorised individuals
          Only suitable for a small filing system due to the number of same or similar
            names
          Prone to cause misfiling due to above


Sequential Numeric – records are filed in numerical sequence i.e. 1,2,3 etc

Advantages
    Allows fast and efficient filing of records
    All growth is at end of filing system
    Easy to use and requires minimum staff training

Disadvantages
    Growth rate is not even in filing system, requires move back whenever
      records are culled
    Prone to misfiling due to transposition of case record numbers

Terminal Digit – records are filed primarily by last two digits then preceding digits i.e.
123456 file on shelf 56 then by preceding digits 1234

Advantages
   More secure as requires staff training to operate
   Even growth rate throughout filing system
   Can be used in conjunction with a colour coding system to prevent misfiling

Disadvantages
    Requires staff training to operate
    Requires a minimum of 100 separate filing areas or bays to operate system

Date of Birth

Advantages
   Does not need a Master Patient Index
   Easy to use, minimum staff training required




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      Disadvantages
       Growth rate is not even in filing system, requires shift back after culling
       Dates of birth are not unique and therefore only suitable for use in a small to
         medium sized filing system
       Less secure and open to access by unauthorised individuals
       Not all patients know their DOB


14.      Storage Systems

Records can be physically stored in a number of systems. The advantages and
disadvantages of each of these are detailed below:

Filing Cabinets
     Filing Cabinets (4 drawer metal filing cabinets)

Advantages
    Lockable, easily accessed and may be fire proof, dust proof

Disadvantages
    Not efficient unless used for a small records system
    multiple staff access is difficult
    Takes up considerable floor space

Static Shelving (purpose built metal racking usually no more than 6 shelves high with
supports at 12 inch intervals)

Advantages
    Allows multiple staff access, fast and efficient retrieval of records
    High storage capacity per square metre floor space
    Suitable for current records where the retrieval rate is high and records
      require to be accessed by multiple staff members

Disadvantages
    Not lockable, dustproof or fire proof

Mobile Shelving (purpose built metal racking usually no more than 6 shelves high
with supports at 12 inch intervals, filing bays are mounted on mobile units which are
attached to rails. These mobile units can be moved using gear assisted handles or
are electric)

Advantages
    Can be made lockable, very high density storage per square metre floor
      space, suitable for storage of non current records or where retrieval rate is low

Disadvantages
    Does not enable multiple staff access, not suitable for storage of current
      records if these require to be frequently accessed by multiple staff working
      simultaneously



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       Can be dangerous if staff do not operate shelving units safely e.g. use of isle
       locks etc

Carousel (a mobile circular filing unit with multiple shelves)

Advantages
    Suitable for smaller filing systems such as GP practices, occupational health
      records, speciality health records, e.g. AHP
    Enables easy access to records, filing unit can be easily accommodated
      within an existing office

Disadvantages
    Difficult to move due to weight, can tilt if not evenly loaded, not fire proof

Lectriever (electric rotational filing system which is operated at desk top level)

Advantages
    Suitable for smaller records systems
    Very confidential as whole unit is lockable
    Fire proof to a degree
    Enables high density storage within a confined area
    Dust proof
    Excellent for storage of particularly sensitive records e.g. mental health and
      genito urinary records

Disadvantages
    Limited access, only one operator can operate at a time
    Loading weight must be easily distributed
    Costly to install and maintain



15.   Secure Transportation of Records and Business and Personal Health
Information

To comply with the Data Protection Act 1998 and the Human Rights Act 1998 and to
conform to Caldicottt principles it is necessary to ensure that data which can be
linked to an individual (either patient, staff or visitor) which is sensitive or confidential
in nature or business sensitive, is transported in a secure manner.

The transportation packaging method will be determined according to the means by
which the data or record is to be transferred.

15.1   Transportation Packaging Methods

A number of handling and transportation packaging methods may be employed for
the secure transfer of physical records within NHS boundaries and to partner
organisations. These include:
    Single record envopak carriers with seals
    Multiple record envopak carriers with seals


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      Pneumatic tube carriers
      Brown paper envelopes
      Brown paper and string
      Non-tearable textured envelopes
      Purpose designed plastic boxes with seals
      Lockable pilot bags

Transportation packaging methods employed must be fit for purpose and in
accordance with local NHS Board procedures for the transfer of records and
personal / business sensitive information. All returnable transportation packaging
methods should be permanently printed with the departments return address in order
that they can be returned and easily identified in the event of the data / records going
astray.

15.2   Privacy Markings

Privacy markings should always be used on envelopes / packages containing
business or person identifiable information

‘Confidential- Clinical Information’ – for all patient identifiable information of a clinical
nature

‘Confidential – Personal Information’ – for personal identifiable information which
should be opened by the addressee only

‘Confidential – Business Information’ - for business information or corporate records

15.3   Internal mail / transportation

Data and records being physically transported by NHS staff or approved contractors
within NHS board boundary

It is imperative that any data or records containing business or person identifiable
information are transported internally using one of the approved transportation and
packaging methods.

The delivery address should be written in full, legible and visible

Bundles of health records must be securely tied in a manner which prevents patient
details being visible

Data and records must be transferred using appropriate trolleys or cages and never
be deposited and left unattended in areas that are not secure e.g entrances,
corridors, stairways or in vehicles where the package is visible or the vehicle
unlocked

On no occasion should transit envelopes be used for the transportation of business
or person identifiable information

Privacy markings should always be used on the approved packaging method and
wrappings / envelopes marked with the return address

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15.4   External mail / transportation

Data and records being transported via approved couriers, taxis or Royal Mail

The suggested service used to mail data and records is Royal Mail Special Delivery
as this service offers a tracking facility which allows the sender to check the safe
arrival of the records.

Whenever it is necessary for data and records to be delivered by taxi or special
courier staff should ensure that they are using a company which has been approved
by their NHS Board.

Data and records should be double wrapped (best practice is to use non tearable
envelopes or packaging). Both layers of packaging should be addressed to the
named recipient or department, the inner layer should bear the appropriate privacy
marking. Both layers of packaging should have a return address.

15.5   Transportation in vehicles

If you require to take records, files, notes of other correspondence containing
business or person identifiable information outside your base location in order to
perform your duties, this should be subject to a risk assessment and approval by the
appropriate line manager ensuring adherence to Data Protection, Caldicott, NHS
Scotland and local NHS Board policies.

During working hours any records, files, notes or other correspondence containing
business or person identifiable information must be stored locked in the van or car
boot.

Where health board vehicles are used and parked on NHS premises overnight, the
vehicle must be emptied of all data and records to a secure storage location at the
end of each day.

Where private vehicles are used when visiting a patient or staff member only the
relevant paper work should be removed from the vehicle. All other paper work must
remain locked in the boot. Outwith working hours the best practice is to return, files,
notes or other correspondence at the end of the day. However it is recognised that
this is not always practical. If data or records cannot be returned they should be
taken into the staff members home in a locked carrier. You should refer to your local
NHS Board policy for guidance.


16.    Retention and Destruction

Minimum retention periods for both Health and Administrative records can be found
in the Scottish Government Records Management NHS Code of Practice (Scotland)
version 2.0.




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You should familiarise yourself with the minimum retention periods for the records
which you administer in your job and the procedures for secure destruction of these
in accordance with your NHS Boards retention schedule.




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17.    Trainers support material –Part 2

Trainers can use some /all of the support material provided below or add their own
as appropriate for their candidate groups.

TASKS

Prior to the start of each Module candidates should complete the Tasks showing in
their workbook and provide within their portfolio evidence of:
 Any required written communication
 Leaflets / policies etc
 Reflective statements

The tasks have been designed to support the trainees understanding of the various
topics / heading within each module. Trainers could use the TASKS to start each
training session, getting candidates to provide a recap of completed tasks.


Discussion Prompts

Discussion prompts can be used to instigate discussion during the training session.
These could be adhoc discussions directed at the whole class or set questions
passed out to individuals or discussed in small groups.

The prompts documented below are only a suggested list of prompts to use to
support the trainees understanding of the various topics / headings within the module
/syllabus. Trainers are encouraged to use or add their own discussion prompts as
they feel is appropriate to their candidate group.


Scenarios

Suggested scenarios have been included to support the trainees understanding of
the various topics / headings within the syllabus. These could be used in small
groups and feedback to the whole group during the training session. Trainers can
use these scenarios, or add their own scenarios as they feel is appropriate to their
own NHS board or candidate group.




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18.       Session 2 - Tasks

Heading - What is a health record / types of health record

Give examples of health records used within your department / service to provide
patient care. Describe the following for each record type below:
        Format of case record filing number
        Whether the record is paper / electronic or both
        Filing system used
        Storage system used for current / archival and off-site (if this is used)

Trainer note– e.g maternity record
    6 digit number prefix by M
    Paper
    Simple terminal digit filing system
    Metal / mobile shelving.
    Archived after 10 years to Iron Mountain off site storage firm



Maintaining patient demographics – List the ways in which your department may be
informed of changes to patient demographic data.

Trainer note – the possible sources of patient demographic changes include -
referral letters, attendance at A&E , inpatient / daycase admission, patient telephones,
patient registration form.

Describe the process for the following:
       CHI – notification of an incorrect CHI number
       Updating patient home address details
       Updating GP details

Bring along a copy of the relevant sections explaining these processes from your
departments training manual.


Heading - Caserecord Tracking

         List the steps you would take to search for a missing record

         Explain the possible implications of not tracking a health record accurately

         Bring along a copy of the relevant section from your departments training
          manual explaining how to track a caserecord


Heading - Patient record storage systems

Describe the policy in place within your NHS Board for loan and return of case
records to other Health Boards.


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Heading - Death notification

      Bring along a copy of a death notification form / listing

      Make a list of who is likely to advise your department of a patients death

      Describe the procedure for recording death details in your department

      What is the impact if deaths are not recorded timeously?

      Find out which other departments are routinely notified whenever a patient
       death occurs


Scenarios

1. Two patients have attended the hospital A&E Department for treatment following a
road traffic accident. Both require to be admitted to hospital and you find that they
are here on holiday from France. They do not speak English and one of the patients
is deaf and dumb. You are required to admit them onto the PAS / PMS describe the
steps you would take to:
       a) to communicate with each of the patients
       b) to record their permanent home address and holiday address
       c) to establish their overseas visitor status
       d) to record their GP details including full practice address

A police officer arrives asking you if the patients have been admitted and requests
clinical information concerning the condition of both of the patients. What would you
do?

2. A GP practice telephones advising that a patient has died at home. Describe the
following:

       a) What information do you require to take down from the GP Practice
       telephone call?
       b) Who do you inform?
       c) What is the process for cancelling outstanding appointments and waiting
       list entries?
       d) How is the patients caserecord updated and what happens to the record
       after it has been updated?
       e) What information is entered into MPI to record the death?

Trainer note – These scenarios may be used for discussions within small groups.
It should be noted that some of the answers required are covered in later modules.

Discussion prompts

Trainer notes – the feedback from the candidate tasks should promote adequate
discussion to cover the content of this module.




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