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Clinical Record Keeping Policy and Standards (P6)

This policy aims to ensure that the clinical records made by staff are fit for purpose and of a quality that provide for objective, accurate, current and comprehensive information that supports and enables the best clinical care and treatment for the patient/client. This policy has incorporated a range of best practice and related legislative requirements to outline the organisations expectations for clinical record keeping standards, both on paper and electronically. The policy provides support to the organisation in meeting its statutory and legal obligations as laid down by the Records Management: NHS Code of Practice 2016; Data Protection Act 1998 section 7, General Data Protection Regulation 2018 and relevant professional bodies. The policy also identifies the standards expected of all registered and non-registered staff. It sets a minimum standard, which will be applicable to all patient settings, including community clinics and inpatient areas. This policy does not replace standards set by professional organisations, but is complementary to them and should be used in conjunction with them.

Opportunistic Maggots Guidance (G274)

Every year during the hot weather we experience an increase in patients with opportunistic maggots in the community. This guidance is to aid assessment and management of these patients.

Disclosure Ref 202483 - IT Infrastructure.pdf

FOI disclosure regarding IT Infrastructure for desktop management, data centre, server management, networking and IT security

Nail Surgery Protocol for Podiatrists (S72)

The purpose of this document is to provide an evidence based approach to the diagnosis and podiatric management of ingrown toenails.

Requesting and Managing Pathology Results within DCHS Community Hospital Wards SOP (S98)

The purpose of this Standard Operating Procedure (SOP) is to outline the steps required to effectively manage the requesting, receiving, filing and actioning of all pathology results by either an electronic process or by a relevant paper-based system. Utilising an electronic system (such as ICE) enables pathology requests to be requested, reviewed and actioned electronically via the electronic patient record within TPP SystmOne. There are an estimated 1.12 billion pathology tests undertaken each year in England (NHS England, 2020) It is imperative a record of all pathology samples is accurately maintained to avoid patient harm and improve patient outcomes (WHO, 2021). The Care Quality Commission (2021) inspects the management of test results to ensure processes are robust, practice is safe and care is effective.

How do I extract an S1 prescribing report

How do I extract an S1 prescribing report

SOP for the Archiving of Records.docx

Archiving of records

How do I extract an Emis Web prescribing report

Disclosure Ref 2025113 - Derby & Derbyshire Joint Area Prescribing Committee Traffic Lights Classification .pdf

FOI Disclosure Ref 2025113 relating to Derby & Derbyshire Joint Area Prescribing Committee Traffic Lights Classification

SOP Titration of Heart Failure Medication by Designated Nurses (S8)

This procedure has been developed to support trained designated nurses to alter the dosage of cornerstone therapies and loop diuretics for this specific group of patients