Sending Patient Notes and Referrals in IUC.

Introduction

To ensure patients receive the appropriate care, it may be necessary for some patients to be referred from Severnside IUC to another service to continue their care. To ensure the receiving service can provide the best patient care, it is important they have timely access to accurate patient notes.

OBJECTIVES OF THE PROCEDURE

This procedure will set out how to store, send and delete onward referrals.

THE STANDARD OPERATING PROCEDURE

During a consultation it may be necessary for a clinician to refer a patient to another service, to enable a safe transfer of clinical care the handover may need to be accompanied with either a written referral form or a copy of patients notes.

Sending patient notes:

1. Patient notes are now visible on Connecting Care within 45 minutes, once the Adastra case has been closed. Most organisations within BNSSG should have access to view this, therefore this should be the primary transfer route for patient notes.
2. If the receiving service is unable to view Connecting Care, the notes could be sent via NHSMail. In this instance:
3. The clinician should contact the shift manager with the case number and email address to send the patient notes (this should always be a NHSMail account). Clinicians should not send the patient notes from their own email account.
4. Shift manager to open the case on Adastra, once the clinicians has completed their notes, ‘print to PDF’ and save in the ‘Patient referral’ folder on the relevant drive, see appendix 1.
5. The shift manager to send the patient notes from the severnside.referral@nhs.net email account and delete the form from the ‘patient forms folder. You must only access this email account from the BrisDoc computer you are working on, under no circumstances should you access the account from personal devices.
6. Host and shift managers should check daily to ensure the patient referral folder is empty. If any documents are found to be left in the folder, an incident form should be completed, and the file deleted.

Sending patient referral forms:

1. The clinician will complete the relevant form and save it in the ‘patient forms’ folder, see appendix 1 for file path at each location, using the Adastra case number and patient initials as the file name. If the clinician has printed the form and hand wrote on it, this can be scanned and emailed if they are at Osprey Court, all other locations the form will need to be redone and saved on the computer. When scanning, the document should be saved to the same folder details in appendix 1. Clinicians should not send the referral form directly to the recipient from their own email account.
2. Once the referral forms are saved in the relevant patient folder for the PC they are working on, the referring clinician should email the patient referral form from their own NHSMail email account to the shift manager via the severnside.referral@nhs.net email account.
3. If the referring clinician does not have an NHSMail email account, they must speak to the treatment centre Host so that they can email the referral form to the shift manager on behalf of the clinician. NHSMail email accounts must be used at all times.
4. Once the referral form is received from the clinician, the shift manager will send the referral form from the severnside.referral@nhs.net email account and should then delete the form if it originated from Osprey Court. You must only access this email account from the BrisDoc computer you are working on, under no circumstances should you access the account from personal devices. The email account has a template saved for the email structure, and Appendix 2 details this, inc subject line. As Shift Manager you must include your name and role in the email.
5. Please ensure that we are only sending referral forms to secure email accounts. I.e. NHS mail and Hospital Trust email accounts
6. Hosts should check daily to ensure the patient referral folder at each location is empty and this is confirmed on the Equipment checklist. Shift Managers should check at the start of their shift, monitor this account throughout their shift and then complete one final check at the end of each shift to ensure the folder is empty. If any documents are found to be left in the folder, an incident form should be completed, and the file deleted.

Out of office email – wording

As this is not a monitored email account, the following wording will be set as an out of office:

Please note this email account is not routinely monitored, if you have any queries regarding the referral please call us directly via the Professional Line – 0117 2449283

 

Appendix 1

Location	File path
Osprey Court	O:\Integrated Urgent Care Service (IUC)\Patient Forms
Cossham	C:\Non trust directorate\Brisdoc\Patient Forms
Clevedon	Download or documents folder
Marksbury Road	G:\Shift Manager\Patient Forms
168 Locking Road	Desktop\Paitent Forms
Greenway	Desktop\Paitent Forms

Appendix 2

This email structure should be used for all referrals sent (included as a template in the referral email account):

Subject line –  Case number – Patient <medical speciality> referral form e.g. Patient TIA referral form

Body of email – Must contain the name of the clinician the referral is being made by, and patient initials. You must include your name, the service name and your job title as the sender.e.g.

Dear TIA clinic

Please find attached a referral for patient JD following consultation with Dr Creavin. 

Many thanks, 

Nat Ryan, Shift Manager, SevernSide IUC 

 

 

 

 

 

 

 

 

 

 

MONITORING

The IUC Team Managers will check this account weekly to check the password is correct, the password will be changed in line with NHSMail timeframes.

Sent emails should be kept for twelve months for audit purposes, any emails older than this should be deleted by the IUC Team Manager during the Friday check.

The above checks will be added to the IUC Friday Checklist.

Each base manager will check the patient referral folder at their base weekly to ensure the process is being correctly followed. Any examples of the process not be adhered to should be reported via the BrisDoc incident reporting process.

RELATED DOCUMENTS

Content of document.

 

 

CHANGE REGISTER

Date	Version	Author	Change
11/02/2021	V2	Julie Marshall	Adjustment to indicate that all referrals should be sent by the shift manager.
15/02/2021	V3	Julie Marshall	Email retention period amended from 12 weeks to 12 months.
16/02/2021	V4	Julie Marshall	Requirement for the frequency of the patient forms folders to be checked amended.
24.05.2023	V5	Lucy Grinnell	Full SOP review and update of file paths and bases
26/09/2023	V6	Nat Ryan	Inclusion of Appendix 2