Policy News - 18 February 2020

The following policies have recently been ratified by the Trust’s Policy Committee.   Please take the time to review those which may be relevant to your role.  

Clinical Record Keeping Policy

The aim of the policy is to provide a framework for all South Tyneside and Sunderland NHS Foundation Trust staff to maintain high standards of record keeping, regardless of format, across clinical services on all hospital and community sites. The policy takes account of a mixed paper and electronic environment.

The material changes within the new policy from the legacy South Tyneside and Sunderland documents include:

• A greater emphasis and a more generic description of electronic clinical records.
• Consistency with other policies around portable electronic devices, with emphasis on Trust-supplied devices, appropriate information governance and professional accountability.
• An appendix of preferred clinical abbreviations, acronyms and symbols to be used in any documentation formats. There is also a list of abbreviations that should not be used as they can have multiple meanings and present a risk to patients if misinterpreted.       

The policy applies to all staff with direct patient contact, inclusive of locums, agency and staff on honorary contracts and volunteers.

View policy

Patient Identification Policy

The Trust is committed to providing a safe environment for its patients as well as recognising the needs and respecting the dignity of the individuals for whom it provides care.  This policy provides a framework to ensure the correct identification of patients at all times whilst under the care of the Trust – both within the hospital and community setting

The policy is applicable to all staff groups that must positively identify the identity of a patient.  It also sets out the Trust position of using a single type of patient identification wristband.

View policy 

Clinical Handover Policy

The National Patient Safety Agency defines handover as ‘The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis’.  Clinical handover is more than this; it is vital that the relevant information is passed to another person or professional group and that the information is communicated in a timely manner, such that patient care at all times is safe and effective and progressive.

Failure to handover appropriately can be a major contributory factor to subsequent error and harm to patient; leading to lapses in care, including delayed decision making, repeated investigations, incorrect diagnoses and incorrect treatment.  How the information is transmitted and recorded in the handover process has a major impact on the way it is retained and acted upon. 

This policy provides a framework for the delivery of a safe and robust clinical handover, which preserves confidentiality and ensures that all important information is conveyed.

This policy cannot be prescriptive about all the specific issues to be handed over because of the complex interactions between the multidisciplinary teams within the Trust, and between other organisations.

The policy reflects the mixed paper and electronic environment of the clinical workplace.

View policy