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MANAGEMENT OF PATIENT DOCUMENTATION

This guide outlines the four critical strands of patient documentation management at Royal Shrewsbury Hospital: managing documents, recording information, handling telephone calls, and generating outgoing letters. Each patient creates a unique set of documents, including anticoagulation requests, warfarin charts, and discharge summaries. The importance of maintaining accurate records, ensuring the integrity of communications, and having an audit trail of documentation are emphasized. This comprehensive approach is crucial for improving information management and patient care outcomes.

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MANAGEMENT OF PATIENT DOCUMENTATION

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  1. MANAGEMENT OF PATIENT DOCUMENTATION Robert Speak Royal Shrewsbury Hospital

  2. There are four strands • Dealing with documents • Recording the information • Handling telephone calls • Generating Dawn letters

  3. Dealing with documentsEvery patient generates a ‘set’ of documents • Request for anticoagulation form • Warfarin charts • Information letters • Copies of correspondence • Discharge summaries

  4. Scansoft’s Pagis Pro

  5. Pagis – main screen

  6. Pagis search

  7. Pagis document

  8. Recording the Information • Key information • Where did it come from? • Written evidence? • ‘Contractual’ fields – link to scanned images in Pagis

  9. Treatment maintenance

  10. Document recording

  11. 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?

  12. Outgoing Documents • Wordlink • No audit trail • How can you be certain? • Can you prove it?

  13. 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

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