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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.

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Disclosure Ref 2025231 - Contracts and spent for Digital Smart Buildings Platform, Fire Alarms , Fire Suppression, Access Controls, Intruder Alarms, CCTV, HVAC (Heating Ventilation Air Conditioning), .doc

Freedom of information disclosure relating to contracts and spend for Digital Smart Buildings Platform, Fire Alarms , Fire Suppression, Access Controls, Intruder Alarms, CCTV, HVAC (Heating Ventilation Air Conditioning), BMS (Building Management System) and Care Comms

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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.

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Recognition of the Deteriorating Child Policy (P93)

The aim of this policy is to set the minimum standard and frequency for monitoring and recording Child patients’ vital signs in their own home, Urgent Treatment Centres and Outpatient Podiatric Surgery. The mismanagement of deterioration is a common area of systemic failure in avoidable patient death across the NHS and poor communication is a leading cause of adverse events in healthcare. The Paediatric Observation Priority Score (POPS) offers a common language to describe and communicate a child’s acute illness severity by all healthcare professionals in all settings and is central to establishing a national pathway for improving the management of deterioration and sepsis.

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INR Testing procedure within Derbyshire Community Health Services by Podiatry Surgery at Ilkeston and Buxton Hospitals (S128)

Only podiatric surgery with the relevant equipment, training and framework in place will be able to utilise this procedure. This clinical procedure will support clinical staff in practice to include arrangements with regards the procedure of the taking of the INR test, quality assurance /quality control, Control of Substances Hazardous to Health (COSHH) assessment, Infection control measures, and any relevant Health and Safety issues. In line with recommendations within the Medicines and Healthcare Products Regulatory Agency (MHRA) Device Bulletin “Management and use of In Vitro Diagnostic (IVD) Point of Care Test Devices DB 2010(02) February 2010

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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

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Standard Infection Prevention and Control Precautions Guidance (G283)

G283 - Standard Infection Prevention & Control Precautions Guidance (Section 5.5 in P69)

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Disclosure Ref 2024231 - Carbon reduction contract and spend.pdf

Freedom of information disclosure regarding carbon reduction, Digital Strategy & printers

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Disclosure Ref 2025298 - Direct engagement software.docx

Freedom of information disclosure relating to direct engagement software

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Think Delirium! Guideline for Managing Delirium (G59)

Think Delirium! Guideline for Managing Delirium