MANAGEMENT OF PATIENT DOCUMENTATION

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MANAGEMENT OF PATIENT DOCUMENTATION

• Robert Speak
• Royal Shrewsbury Hospital

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There are four strands

• Dealing with documents
• Recording the information
• Handling telephone calls
• Generating Dawn letters

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Dealing with documentsEvery patient generates a
set of documents

• Request for anticoagulation form
• Warfarin charts
• Information letters
• Copies of correspondence
• Discharge summaries

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Scansofts Pagis Pro
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Pagis main screen
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Pagis search
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Pagis document
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Recording the Information

• Key information
• Where did it come from?
• Written evidence?
• Contractual fields link to scanned images in
  Pagis

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Treatment maintenance
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Document recording
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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?

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Outgoing Documents

• Wordlink
• No audit trail
• How can you be certain?
• Can you prove it?

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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