News from our Medical Director Dr David Birkenhead

I appreciate this is a time of huge change and speed of change and I wanted to open this update by thanking  you all for your continued support, teamwork  and dedication to delivering compassionate care for our patients.

I wish to use this opportunity in CHFT Weekly to remind colleagues of one of the cornerstones of that care, a very important “must do”.

You may recall a year or so ago we did some improvement work around the standard of documentation in both the medical and nursing notes. This followed a warning from the CQC, which was eventually lifted once we had demonstrated the required improvement. Unfortunately we are seeing some evidence that our standards of record keeping are once again slipping and have recently received a notice to improve from Her Majesty’s Coroner.  She was concerned about the standards of both the medical and nursing record when reviewing a recent case.

Accurate records provide the essential information required to deliver care to patients in a safe manner and to allow us to learn when things go wrong. Each page must include the patient’s name and identification number.  Records must be legible, be entered chronologically and be made at the time of the care episode. The person making the note must sign and print their name and include the date and time. Whilst I understand that everyone is busy and pressed for time it is important that we don’t take shortcuts. It is not an extra it is essential.

Effective communication has to be at the heart of a safe patient journey. We introduced new standardised nursing documentation 18 months ago which details all the risks associated with a patient which means we can be sure they are on the right plan for their needs. A lot of work has been done and colleagues feel it provides a good assessment however we need to make sure it is completed fully and the information is effectively communicated between shifts.

Please click onto the link below and refresh yourself of the standards expected.

2  Moving on to a related topic we are currently doing some work to improve our clinical coding. Again this depends in part of having a complete and accurate clinical record and it is important because the information is used to record how unwell patients are under our care. This affects both the payments made to the Trust for the care we provide and affects some of our quality indicators such as SHMI. We currently do not perform well with coding when compared to other Trust, and we estimate that as a result we lose over £1 million in income per year.

I am sure you will be aware of the financial challenges we are currently facing and we simply can’t afford to continue losing this money. In order to help we have introduced a simple one page proforma that we are asking the medical staff to complete when they admit a patient. Unfortunately this is happening less than 20% of the time so please try to remember, and if you see notes without a completed proforma please remind colleagues to complete one if you are unable to do so yourself. It is also important that we use the correct terminology so here is a quick reminder;

Right to use

  • A definitive diagnosis
  • “Treat as…”
  • Probable
  • Presumed
  • Symptoms where  no definitive diagnosis is given

Avoid

  • Differential diagnosis
  • Possible
  • Likely
  • Maybe
  • Suspected
  • ?
  • Impression

 

I do hope we see start to see a big improvement and urge you all to give this your attention. I would be interested to hear of any ideas you have to help us to improve our record keeping or coding further so if you have any ideas, send me a note or email. You can also contact our clinical coding assistant lead diana.wilson@cht.nhs.uk if you have any questions or need advice on this issue.

 

Many Thanks