We are in the process of transferring to an EPR system. Currently, our medication and some of our documents are electronic but we have still lot of documents in paper.

Whilst the patient is in critical care they will have a set of ‘Pink’ critical care notes. These are a different set of notes to the brown case notes and allow all information regarding the critical care stay to be easily accessed. It is vital that all documentation during the critical care stay is within these pink notes (especially notes from parent/visiting teams). The ward clerks photocopy the pink notes and transfer the copies to the hospital “brown” notes. 

There is an admission document included in every set of pink notes. It is vital that all necessary information is recorded in the admission documentation at the time of admission. If the patient requires intubation and ventilation it may be several days before the patient can communicate for further history. All sections of the admission document should be completed including the patients’ weight and height. If the patient is admitted from theatre, peri-operative information such as anaesthetic technique, blood loss, surgical difficulties etc should be recorded. There is space on the back page for a systems based management plan. Please be as thorough (and legible) as possible with all sections.

Sign, print name, GMC number and date/time all entries. 

A new daily sheet is completed by the night shift resident for each patient every day. This includes a summary of the admission, progress over the last 24 hours and a system’s based examination. Ward round and daily progress notes are then written on the back of this sheet. Continuation sheets are available when more space is required. Any blank space on the continuation sheet should be scored out when the next daily sheet is entered to ensure that records are chronological. Visiting teams should be directed to the correct place for documentation. 

There is ongoing audit of documentation. Your notes will be reviewed. Standards include: 

• Patients name and number on every page 
  
• All entries dated and timed ( 24 hour clock ) 
  
• The first entry that every Dr makes during the clinical episode has block capital name, role and GMC number 
  
• All entries signed, legible and in black or blue ink 
  
• Alterations are corrected appropriately ( single line cross out, dated and signed) 
  
• Records are kept chronologically 
  
• Clearly documented history and examination 
  
• Differential or definite diagnosis 
  
• Clear list of investigations and their urgency 
  
• Clear treatment plan and the treatment given 
  
• Evidence that the patient has been seen by a Consultant within 24 hours of admission 
  
• Record of any operation ( where appropriate) 
  
• Evidence of verbal or written information given to the patient and or their carer

All our most recent documentation documents can be found following this link

Electronic Prescribing - ePMA

We have recently moved to the ePMA system which is the  electronic prescription used across the hospital. There is still a paer prescription form to be used in case of the electronic system failure.

All our infusions are available on the ePMA system. Please note that the critical care only prescriptions should be discontinued on discharge of the patient to the ward.

Handover sheets

A ward round jobs book is kept on each unit to reduce the need for you to keep your own jobs list.

If you do feel the need to have your own list or handover sheet, please ensure it does not contain identifiable patient details and that it is disposed of in a confidential waste bin or shredder.

The trust regards lost handover sheets as a major breech in patient confidentiality and will take disciplinary action accordingly.