MANAGEMENT OF PATIENT DOCUMENTATION Robert Speak Royal Shrewsbury Hospital
There are four strands • Dealing with documents • Recording the information • Handling telephone calls • Generating Dawn letters
Dealing with documentsEvery patient generates a ‘set’ of documents • Request for anticoagulation form • Warfarin charts • Information letters • Copies of correspondence • Discharge summaries
Recording the Information • Key information • Where did it come from? • Written evidence? • ‘Contractual’ fields – link to scanned images in Pagis
Telephone Calls • A lot of information passed this way • Do you log all calls? • Test the accuracy of the data? • Record of any advice given?
Outgoing Documents • Wordlink • No audit trail • How can you be certain? • Can you prove it?
Conclusion • Information management is important – but there are some gaps. • Documentary evidence should be kept. • There should be a record of phone calls. • There should be an audit trail