Protocol
for Computer use in Practice
Adopted
2/11/04 DGH
Guidelines
We have
used the Good practice guidelines for general practice prepared by RCGP to
produce this protocol.
http://www.rcgp.org.uk/clinspec/docs/goodpracticeguidelineselectronicrecords.pdf
We aim to
minimise the use of
paper in our offices.
All
computer users should receive necessary appropriate
training.
All
clinical contacts should be recorded on the computer.
We aim to
keep records which are accurate, readable, traceable, structured and
retrievable.
All
computer users should have induction training on joining the practice and
everyone should have further training periodically.
We aim to
use electronic mail to supplement the usual verbal communication to ensure that
all members of our team receive prompt messages.
We use
Microsoft outlook for in house communication and the NHS net for external
messaging.
We aim to
keep an updated record of our practice procedures and protocols in public
folders.
Our
practice has a website which contains essential information about the services
we offer and we aim to keep this regularly updated.
Requirements for computer
use
Each
computer user has own password and should log on and off their terminal at the
start and end of the session.
All
consultation (telephone, visit or surgery) requests should be entered onto the
appointment system for the appropriate clinician to deal
with.
Changes of
name, address or telephone number must get onto the computer system. It is
important for the information to be kept up to date.
The visits
need to be entered and printouts of summaries prepared for
Each
computer user has own password and should log on and off their terminal at the
start and end of the session.
A computer
data entry should be made with every clinical contact (telephone, visit,
consultation, information, letter) with a
patient.
The contact
type must be entered correctly for each contact with the correct clinician
name.
Information
such as BP, weight, peak flow, smoking status must be recorded so it is
retrievable (read coded). We aim to opportunistically record BP and smoking
status wherever appropriate.
Medication
reviews should be recorded at least annually with the appropriate read
code.
The patient
summary and problem section should be kept up to date and tidy. New diagnoses
will either be entered at the time of consultation by a clinician or by a data
entry clerk on the receipt of a hospital letter.
The repeat
medication list must be kept up to date and accurate and is the doctors responsibility when a letter is read or when a
patient is seen. All medications prescribed for a patient should be entered onto
the computer system.
It is
important that entries are made soon after seeing a patient. Obviously after a
home visit it may be the following day that an entry is made and it is important
that the date of the home visit is correct. A free text entry of the date you
are entering the information could be helpful.
Read coded
diagnoses should be if possible entered with the date when the diagnosis was
originally made. This is of more importance when summarising records. Please
refer to our separate protocol for note summarisation
The results
daybook should be reviewed and cleared at least twice
weekly.
Clear
direction in the form of free text entry should be used to aid other clinicians
if tests or actions are required from another team member.
Read coded
entry is required if a sample is sent to the laboratory so we can do our own
quality control checks to ensure results return to the
practice.
Some tests
like X rays and some microbiology tests are received in
paper form from the hospital. These should be scanned onto the system and then
the paper record is seen by a doctor. We aim to enter a message in free text
attached to the result entry on the computer.
An audit by
the computer manager will be done every 2 months to confirm that we are
receiving all results for samples sent.
It is
important that we can trust the clinical records. If an amendment to the
clinical record needs to be made because the record is incorrect. It is
important that a free text entry is placed in the record at the place of the
piece of data to be deleted explaining why the record is being altered and
giving a date and user name. The system has an audit trail so will be able to
identify if someone has changed the record. This has important legal
implications.
The
medication record can be edited and it is important that prescriptions printed
in error but never dispensed should be deleted. The software permits this to be
done but requests a reason to be typed onto the screen. Clinicians and
receptionists all need to be able to do this
Electronic
Communication
To
supplement the normal verbal channel of communication it is very helpful to use
the in house e mail system. This allows us to disseminate important clinical and
organisational information quickly, accurately and comprehensively to all team
members.
E mails
should be viewed during each session a clinician performs. Keeping the Microsoft
Outlook open during surgery is a valuable method of instant messaging without
the need to interrupt a consultation.
It is
helpful if e mails have a title as this aids recall of information if
required.
It is
important that everyone can use Microsoft Outlook on any terminal they are
likely to use.
We
communicate important information regarding the death of a patient to all team
members on the receipt of this news via internal electronic mail. No patient
specific details are sent on the external e mail system.
Incoming
clinical mail (discharge letters, out patient information, out of hours letters, paper test results, insurance letters and
communication from patients) should be scanned onto the system the day they are
received. The paper record is then distributed to the responsible clinician.
Paper records are kept in a temporary file after this.
It is
important that scanned documents are scanned into the correct patients record and the document is
readable.
The sources
of information for all staff working in the organisation are kept in the public
folders section of Microsoft outlook, on Leeds Health Pathways, on our own
website and in the DXS software on our system. Access to the internet should be
available at each PC in the practice.
We expect
our team members to abide by NHS guidance regarding accepted use of the internet
ie to use the web access for our own education and the
benefit of patients only. It is not acceptable to try to access another persons mail or send mail in another name. It is unacceptable
to knowingly spread computer viruses.
Computer
held information is backed up on a daily basis and the tapes are kept in a fire
proof safe. Another copy is kept off site.
The back up tapes are regularly validated by the computer
supplier.
Confidentiality
We have a
separate policy for confidentiality. The level of access to detailed
computerised information varies dependent on whether the user is a clinician,
medical secretary or receptionist.