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Clinical Information Assurance – Primary Care Trusts Guidance For Clinical Information Assurance the following information defines relevant systems, policies, processes and procedures as well as key elements in document control and should be used when PCTs are assessing individual requirements. All references to data and information quality refer to patient information for the purposes of assessment, although many principles could be applied to other information (such as manpower, finance etc). PCT procedures should cover all types of patient activity where data is collected onto relevant systems. ‘key systems’ are defined for this version as key operational systems which would be linked in for the NHS Care Record Service. The Patient Administration System (PAS) is often the main database for most data used, but other systems (e.g. Pathology, Radiology, A&E systems) which are used for the operational delivery and organisation of care would also be included. A Policy should be a high level statement of the PCTs intended approach towards a specific issue or objective. Key content should include o A section specifying why the Policy is required o The specific intentions of senior management in relation to the Policy o A description of the Policy accountability and reporting arrangements and staffing structures o PCT staff duties and responsibilities in relation to the Policy o A process for monitoring the Policy o A description of links to any other initiatives o Actions to be taken if the Policy is breached A Procedure should be a detailed set of instructions to ensure consistency of information recording between different staff members and over time. It should be sufficiently detailed to allow an appropriate new staff member to undertake the task to the required standard. A Process is defined as the practical workings of one or more procedures that are linked in order to meet a Policy requirement In order to maintain standard Polices and procedures and to ensure that they remain current and up-to-date, some form of document control system will be needed within the PCT. This could be manual, or an electronic system. Either way it must cover the key elements of Document Control, namely: • Standard PCT format; • Named author • Unique Document Reference; • Version and / or Issue number • Date of Issue • Review Date; • Areas of responsibility with named roles; • A written description of the procedure; • Flow charts, glossary and/or an index.
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