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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
HIRS – location and hours of operation Level 1, G Block (Beneath Emergency) Department is staffed 24/7 – after hours access by arrangement Accessing Health Care Records o All information contained in a health care record is CONFIDENTIAL. o Health care records are sent to ward ONLY for patient care. o Clinicians are NOT to remove the health care record from the Hospital (i.e. taken home, put in car). Accessing Health Care Records Health care records can be viewed in our research room for the following purposes: o Research o Case Reviews o M&M Meetings o Peer Review o Quality Audit o Complaints Clinical Documentation Documentation must be sufficiently detailed to allow other health care personnel, of the same discipline, to assume care of the patient or to provide ongoing care at any time. Clear, accurate documentation is also of critical importance for clinical coding and assignment of DRGS, or other casemix classifications as well as review in clinical, research and legal settings. o Legible and in English or accepted clinical terms o Accurate, precise, objective and factual o Timed (using a 24 hour clock) and dated (day, month and year) o Signed by the author and include their printed name and designation o Electronic systems require appropriate identification e.g. electronic signature o Written in black ball point pen (for handwritten entries) o Fluorescent markers, textas or gel pens must not be used because of reduced reproducibility and durability o Must be sequential where possible without space between or within entries. o Must only use abbreviations and symbols approved by the area. Refer to the area procedure on ‘Approved Abbreviations for use in the Health Care Record’ o Entries by students must be countersigned by their supervising clinician o Details omitted from an entry and subsequently recorded should be made under the heading of ‘ADDENDUM’. The entry should record the date and time of the omitted event and date and time of the addendum. o An original incorrect entry must remain readable, correction fluid is not to be used. No alteration or correction of records is to render information illegible. o A correction may be made as a single line through the original incorrect entry or ‘strikethrough’ text in electronic records, record “written in error”, followed by person’s name, signature and date of correction. o Privacy laws permit a patient to request a health service to amend their health information All entries should be made as close as possible in time to the events and actions they record. Where there has been delay between events and the documentation of them in the health care record the time of events must be noted and the entry must be noted as being made “in retrospect”. Acute Care Settings oMedical staff must make an entry o on initial presentation o on admission o Monday to Friday at minimum daily o at least once on a weekend o on discharge o Other clinicians should make entries to reflect their level of assessment and intervention Long Stay or Residential Settings o Clinicians should make an entry in the health care record o twice per week o on discharge. Discharge summaries are required for: All admissions over 24 hours including deaths. If a health care record is returned to the HIRS department without a discharge summary, staff will page you to complete what is required. If you do not adhere to this the issue will be referred to your Manager oAll discharge summaries/front sheets should commence at the start of the episode and completed as the patient is discharged from the health service but must be completed within 48hours of patient separation and immediately sent to the intended recipient(s) oThe completion of discharge summaries and front sheets remains the responsibility of the relevant medical team. oPlease be aware that your termination paperwork will not be signed off if there are any discharge summaries waiting to be completed What should be included in a discharge summary? oPatient identification data including unique identifier i.e. MRN – Medical Record Number oName, address and telephone number of facility discharging/referring patient oName of the VMO attending the patient o Suitable clinician’s name, title and telephone number(s) for follow up contact o Intended recipients name, address and contact telephone number, facsimile or email address o Episode start (admission) and end (discharge) dates o Presenting problems o Diagnosis/es o Major interventions o A note on the patients progress, complications and co-morbidities during the episode of care o Results of major investigations and instructions for follow up pending results, including telephone numbers of diagnostic departments as relevant. o Discharge medications and changed or ceased medications with reasons for changes o Patient alerts e.g. allergies, adverse drug reactions, advanced care planning o Patient needs e.g. interpreter o Medical specialist and other clinician contacts and appointments o Final diagnosis o Follow up plans o Community health contacts o Community service provider contacts o Author of discharge summary/referral including name, title, date and signature When documenting in an electronic record; o Use upper and lower case letters. Entries must not be typed in all upper case or all lower case o Use correct sentence structure and punctuation o The system default font size / font type is to be used and must not be changed o Use only the abbreviations and symbols approved by the area. o Do not use bold or italics unless this is the default A sample of records are audited each month across the area to ensure compliance with the clinical documentation policy. These results will be published on the intranet by hospital. For further information refer to the area ‘Procedure on Clinical Documentation in the Health Care Record’ An expert certificate is evidence of a person’s opinion stating that the person has specialised knowledge based on his or her training, study or experience, as specified in the certificate and sets out an opinion that the person holds and that is expressed based on knowledge. oExpert Certificates are processed by the HIRS department o The HIRS department will ensure the correct consent has been obtained before you complete an Expert Certificate o An Expert Certificate may be presented instead of your attendance at court o It is important when writing a police statement for assault to include lacerations, bruising, fractures, pain, etc o It is also important to be detailed, for example how deep the laceration is o When a police statement is requested, it is always requested from the most relevant/discharging team. If the police are not satisfied with statement they may request a statement from another doctor (e.g. surgeon) The following information is regarded as sensitive: Hepatitis status, HIV / AIDS related information, information relating to third party, sexual assault, domestic violence, genetics, IVF and artificial insemination program, and child at risk * Mental health information is not considered sensitive if it is for ongoing health care ~~~