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 documents Every 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