Records

Includes care records, including clinical data are written and managed in a way that keeps people safe. Do staff have access to all the information they need to deliver safe care and treatment (such as care plans/notes etc.)? How are crews made aware of up-to-date information around DNACPR/end of life planning? How are records securely stored/managed?  

YESTERDAY  

TODAY  

• Decrease in the use of the old (Toughbook) ePCR system, saw the number of paper care records increase to 50,000+ a month. This increased the number of Datix incidents received for missing or lost paper PCRs.
• Paper PCRs taking the 14 days (or over) to reach a locality office, any urgent requests had to wait until the record was available (with EPCR it is available as soon as finalised)  
• Comprehensive PCR policy available to staff, topics include the minimum data set, record keeping skills, submission of paper care records to medical records, archiving and access to records.
• PCRs are securely transferred to offices and securely held in restricted access offices until scanned. The scanned images are held on Formic Fusion, and only accessible to those departments who require access (i.e., medical records, SARs, Patient experience, patient safety, safeguarding, clinical audit).  
• Use of Private ambulance services (PAS), records not received regularly and unsure who was being used.   
• No access to care plans or notes for patients for previous attendances/GP notes.   

• The Trust is currently implementing the new EPCR iPad system across the trust, which will help reduced the risk of losing paper PCRs.   
• Comprehensive PCR policy available to staff, topics include the minimum data set, record keeping skills, submission of paper care records to medical records, archiving and access to records. Policy reviewed within time frame  
• PCRs are securely transferred to offices and securely held in restricted access offices until scanned. The scanned images are held on Formic Fusion, and only accessible to those departments who require access (i.e., medical records, SARs, Patient experience, patient safety, safeguarding, clinical audit).  
• Station based audits not being undertaken due to pressures within the Trust and substantial increase of paperwork being used (instead of ePCR)  
• New process for use of PAS providers and allocated stations, mean care records are received in a timely manner and mostly compliant with the policy  
• DPIA in place for GP Connect Service to allow clinicians read only snapshot of the patients GP record.  

TOMORROW  

• The ePCR system has will complete its roll out in October 2021 and will reduce the number of paper care records being used across the Trust, less data breaches by the Trust.   
• The new EPCR system will enable for more monitoring to be undertaken with built in reports on the web application  
• Station audits will be undertaken as ePCR system will be fully up and running  
• Review the PAS providers access to the new EPCR system to allow them to use the electronic records software  
• Continue review of the access to care notes and GP notes via GP connect project  
• A project is being developed by external organisations to allow for crews to have access to patients end of life care and DNCPR. (DPIA currently being reviewed by project team IES, WS, NEE CCG)