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An electronic health record (EHR) contains patient health information, such as:
Patient demographics
Progress notes
Vital signs
Medical histories
Diagnoses
Medications
Immunization dates
Allergies
Radiology images
t. religious preferences.
u. ethnicity.
v. spoken language (indicate if an interpreter is needed).
w. accompanied by.
x. school (where relevant).
y. All registration information should be checked on every attendance and
updated where necessary, as this information is essential in the case of an
emergency.
Alerts and allergies
3.3.45 The healthcare organisations procedure regarding alerts and
allergies is adhered
to.
Referral letters
3.3.46 Referral letters are opened by authorised staff (e.g. OPD/Outpatient
Central
Referral Office) on the date they are received.
3.3.47 Referral letters are immediately date stamped on receipt (referral
receipt date).
3.3.48 Referral letters are recorded on an appropriate IT system on date of
receipt.
3.3.49 The date the referral letter is sent for triage is recorded.
3.3.50 Referral letters are triaged by the appropriate healthcare professional
and the
triage outcome and date triaged is recorded.
3.3.51 Referral letters that have been triaged are returned to the relevant
staff (e.g.
OPD/Outpatient Central Referral Office) within five working days.
Part 2
Standards
HSE Standards and Recommended Practices for Healthcare Records
Management, QPSD-D-006-3 V3.0
record entry for acute medical admissions and may also be supplemented
with
additional specialty information:
a. reason for healthcare encounter.
b. presenting problem/complaint.
c. history of presenting problem.
d. estimated length of stay (ELOS).
e. current diagnoses.
Part 2
Standards
HSE Standards and Recommended Practices for Healthcare Records
Management, QPSD-D-006-3 V3.0
This is a controlled document and may be subject to change at any time
Page 32
Content of the healthcare record
f. service user alerts/allergies.
g. past illnesses.
h. procedures and investigations.
i. medications (including over-the-counter and/or non prescription) and
diets including nutritional supplements.
j. social circumstances.
k. functional state (self-care/baseline mobility/walking aids and appliances).
l. family history.
m. systems review.
n. examination findings.
o. results of investigations.
p. problem list.
q. overall assessment.
r. management plan.
s. intended outcomes.
t. information given to service user.
Follow-up entry
3.3.60 The following service user information is included in the follow up
entries for
acute medical admissions:
a. reason for clinical encounter.
b. review of case.
c. overall assessment including any change since previous encounter.
d. management care plan.
e. information given to service user and carers.
Part 2
Standards
HSE Standards and Recommended Practices for Healthcare Records
Management, QPSD-D-006-3 V3.0
This is a controlled document and may be subject to change at any time
Page 33
Content of the healthcare record
Communication with service users
3.3.61 All relevant communication with service users and families is
documented in
the relevant part of the healthcare record.
Documenting consent in the healthcare record
3.3.62 The giving or refusal of consent is easily and clearly identifiable,
either documented
in the healthcare record or on a consent form which is retained as
part of the healthcare record.
3.3.63 Consent documentation clearly identifies the service user by name
and healthcare
record number.
Mortem Examinations).
Deaths reportable to the Coroner
Detailed guidance on deaths reportable to the coroner is given in the
Standards and
recommended practices for Post Mortem Examinations. If the death is
reportable to
the coroner, the following information is recorded in the healthcare record:
3.3.87 The reason why the death is reportable to the coroner.
3.3.88 The name of the person who made the decision to notify the coroner.
3.3.89 The date and time of such notification.
3.3.90 The name of the person who was notified in the coroners office.
3.3.91 The decision taken by the coroners office.