Beechdale Health Centre
Safe Haven Protocols & Guidance
Document Control
A.Confidentiality Notice
This document and the information contained therein is the property of Beechdale Health Centre.
This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Beechdale Health Centre.
B.Document Details
Classification: / InternalAuthor and Role: / Arun Venugopal PM
Organisation: / Beechdale Health Centre
Document Reference: / 1
Current Version Number: / 1
Current Document Approved By: / Arun Venugopal PM
Date Approved: / 30/01/2013
C.Document Revision and Approval History
Version / Date / Version Created By: / Version Approved By: / CommentsCONTENT
Page 3-Using E-Mails Protocol
Page 4-Using External Post Protocol
Pages 5 & 6-Collection of Prescriptions Protocol
Page 7-Receiving and Making Telephone Calls Protocol
Pages 8 – 10-Fax Handling Protocol
Page 11-Message Taking Protocol
Page 12-Guidance for TRANSPORTING personal information
Page 13-Guidance for SHARING personal information BY POST
Page 14 -Guidance for SHARING personal information BY PHONE
Page 15-Guidance for SHARING personal information BY FAX
Page 16-Appendix A - Log Sheet to Record Collection of Prescriptions by
Pharmacies
Page 17-Appendix B - Log Sheet to Record Collection of Prescriptions by
Nursing Homes
Pages 18 & 19-Appendix C – Patient letter template re Patient letter template re
Collecting Prescriptions containing Controlled Drugs +
Form of Authorisation to collect Prescriptions for Controlled Drugs
on behalf of a Patient
Page 20-Appendix D - Controlled Drugs Prescription Collection Record Card
Beechdale Health Centre
Using E-mails Protocol
Sending information by email does not offer 100% security.
Staff using email must not send any patient identifiable or other sensitive information by email unless it has been encrypted to standards approved by the NHS (e.g. NHSmail which has been encrypted to NHS approved standards).
NHSmail accounts are encrypted to NHS approved standards and may be used for sending patient identifiable information to other NHSmail accounts.
Emails containing patient identifiable information
must never be sent to Non-NHSmail accounts.
Email attachments are one of the most common methods for transmitting viruses. Although the Practice has anti-virus software installed on its PC’s, users should NOT open attachments received if they were not expecting them.
Practice email accounts should only be used for business purposes in order to reduce the possibility of virus attacks and data hacking.
Any problems surrounding the use of emails should be reported to in the first instance to your line manager and you should also log a call with the IT Helpdesk.
Security
Staff must ensure they do not share their username and password with anyone within or outside the organisation. Passwords are provided for a reason.
Staff are also required not to leave their email account open and theirPC unattended at any time.
When staff leave their PC, it must be locked by using the Ctrl + Alt keys or by logging off their email account and then locking out of their PC when not using it.
Beechdale Health Centre
Using External Post Protocol
Preparation of external post
External post that requires mailing should be left in the basket marked Post in the.Reception area
Post is prepared for despatch by daily.
Any post placed in the ‘External Post’ basket after this time, may not be processed on that day
All correspondence sent to patients must be headed ‘Private and Confidential’. The ‘Private & Confidential’message must also be stamped on the envelope.
Staff must ensure that the patient’s full name and address, including the post code is detailed on the letter and/or envelope
Envelopes must be sealed to so that they leave the Practice intact. If necessary, use sticky tape to secure the envelope flap
All correspondence being sent to Insurance Companies/Solicitors must be headed ‘Private and Confidential.
When sending copies of patient’s records, staff must ensure they are sent by Recorded Post to a Named Individual - a receipt from the Post Office as proof of payment/posting must be obtained. This type of postage will enable the Practiceto track any undelivered letters/packages
Preparation of post for collection by NHS courier
All post should be prepared as detailed above.
Post for collection by NHS courier must be in Reception, as this is a daily collection.
Staff must ensure items that are to be transported in a vinyl pouch are appropriately addressed to a named individual and department. If the vinyl envelop has a security tag, ensure it is utilised.
Envelopes must be sealed shut before they leave the Practice.
The identity of the Courier must always be checked and verified upon each visit to the Practice:
- View his/ her ID badge;
- Sign the form that indicates that they collected post from you on that day;
- Insert the time of collection and the number of courier bags that have been exchanged must be specified on the form.
Beechdale Health Centre
Collection of Prescriptions Protocol
Patients
Staff will ensure that Patient’s collecting their own prescriptions are asked to confirm their name and address before it can be issued. Any discrepancy should be dealt with at point of contact e.g. change of address.
Friends or relatives collecting a prescription on behalf of a patient must be able to provide the Practice with the Patient’s details (e.g. name, address).
If there are any doubts about the person collecting the prescription, Practice staff will contact the patientto make sure that the individual has been authorised to collect it on their behalf.
Pharmacies
Staff will ensure that prescriptions prepared for collection by Pharmacies are clipped together with a bulldog clip and filed under the correct pharmacy name.
When the Pharmacy collects the prescriptions Practice staff will always check and verify the collector’s ID and ensure their signature is entered onto the log sheet against each patient’s prescription.
Nursing Homes
Staff will ensure that prescriptions prepared for collection by Nursing Homes are clipped together with a bulldog clip and filed under the correct Nursing Home name.
Each prescription to be collected will be entered on that Nursing Home’s Log Sheet (See Appendix B for Log Sheet Template).
When the Nursing Home collects the prescriptions Practice staff will always check and verify the collector’s ID and ensure their signature is entered onto the log sheet against each patient’s prescription.
Beechdale Health Centre
Receiving & Making Telephone Calls Protocol
Receiving Telephone Calls
Wherever possible, Staff will ensure that the Telephone Call is being taken out of earshot of patients/visitors.
The glass panel that screens the Reception area, must be kept closed when speaking on the telephone.
Staff must always statetheir own name, to ensure that the caller is aware of who is dealing with their query.
When receiving incoming calls that require the caller to establish their identity (e.g. where Staff need to confirm something personal or book an appointment), the following questions must be asked:
- Who is calling
- Confirmation of their address/other personal identifiers
- The nature of their call
Under no circumstances should Staff repeat what they have said back to them
If the caller is requesting specific personal information, Staff must be absolutely sure that the caller is entitled to receive it.
If there is any doubt, advice should be taken from their Line Manager
Staff must also be careful when taking messages off answer phones, ensuring that audio messages cannot be overheard by other people whilst playing them back
Making Telephone Calls
Staff must always make telephone calls that involve personal information in an area that is secure and away from people so that the conversation cannot be overheard
Staff must implement the following procedure:
- Verify the identity of the person who needs to be spoken to;
- Keep the level of detail to a minimum – the individual will usually know the reason for the communication
- Never take the person’s direct dial number if they need to be called back at work – always go through the main switchboard
- Do not leave any messages on answer phones that contain personal information. Leave a message which requests the person to call you back, give the correct telephone number and also the Practice name.
Beechdale Health Centre
Fax Handling Protocol
Introduction
This protocol sets out the procedure to follow in order to manage incoming and outgoing paper faxes.
Where faxes are sent or received using computer-based systems see also Electronic Transfer of Patient Data [*]
A faxed document received within the Practice is generally one of four differing types:
- Items relating directly to patient care (clinically-based faxes);
- Items of a non-clinical (administration) nature;
- Unsolicited marketing from unknown firms;
- Unsolicited marketing from known (contact or supplier) firms.
The handling requirements of each of these types is set out below.
General
The fax machine is situated by Secretary’s desk, which is generally occupied most of the time. This ensures that an incoming fax will be noticed by administration staff and will not be left unattended for a long period of time.
The fax machine is designed and positioned so that automatic prints of incoming faxes are received into an integral or suitably fixed or positioned basket to prevent accidental spillage onto floor or other areas where they may become lost.
This also helps to prevent faxes being viewed by unauthorised visitors.
Collection of faxes from the basket will take place several times throughout the day.
Faxes relating to Patient Care
These are likely to comprise:
- Prescription requests,
- Dressing requests,
- Out of hours details,
- Discharge notices,
- Nursing / residential home communications,
- Hospital letters etc.
Processing
Prescription requests and dressing requests are to be passed to the staff member responsible for generating prescriptions for processing in the normal way.
All other clinical communicationsare to be scanned to the clinical system and distributed in accordance with the procedures in place for post distribution.
The staff member responsible for managingreceived faxes will:
- Identify any which have the potential to be urgent;
- Record a suitable note using the message procedure;
- Bring the fax to the attention of the relevant clinician at the first opportunity.
Faxes of an Administrative Nature
Processing
These faxes are not generally urgent and are tobe passed to the person for whom they are intended, or left for them until they return.
In the event of an absence which exceeds 24 hours, these faxesare to be passed to a suitable colleague (where appropriate) for action.
Unsolicited material from Unknown Firms
Unsolicited faxes represent a significant cost to the Practice in terms of paper and toner usage. Since 1999 it has been unlawful to send unsolicited marketing faxes without prior permission, and the Practice has therefore registered with the Fax Preference Service (FPS) to control the number of unsolicited faxes being received.
Fax Preference Service:
Processing
In the event a fax is received which appears to be unsolicited (these are usually of poor reproductive quality and are likely to be addressed to the Practice, rather than an individual), the Fax should be passed to ***Insert Name(s) of Person(s)***.
The policy of the Practice is to report such Faxes immediately to the FPS for them to contact the company and inform them of the restrictions under the legislation.
A copy of the referral will be retained in the practice for 6 months to monitor receipt of subsequent repeat faxes.
Unsolicited material from Known Organisations already in contact with the Practice
These are generally unsolicited marketing faxes from Organisations who have an existing supplier relationship with the Practice.
Whilst these faxes also represent a significant cost to the Practice, they may contain offers on products which may be beneficial.
Processing
These faxes should also be passed to the practice manager who will decide whether the practice wishes to continue to receive these communications.
Where these items are considered to be acceptable then no further action will be taken.
In the event that it is decided that faxes from thatOrganisation are not to be sent in future, a member of the Practice Management Team will contact the data controller or similar official at the Organisation and advise them that the Practice is to be removed from their marketing list / database.
In the event that this action has been takenbut unsolicited faxes continue to be received, this will be reported to the FPS as previously stated.
Outgoing faxes
Staff must adhere to the following requirements when sending a fax:
- Personal or confidential information must not be faxed unless absolutely necessary;
- The minimum amount of data must always be used to convey the communication;
- The data sentmust be accurate, up to date and relevant to the subject matter;
- The fax transmission must be to a named recipient/ department;
- Personal and clinical details are to be faxed separately whenever possible;
- The Patient’s NHS number is always to be used as a unique identifier;
- The recipient is made aware that a fax is about to be sent to them;
- The Practice fax header must always be used - this is marked as private and confidential and follows the Save Haven procedures;
- Wait until the fax machine displays in its information window that the fax has been sent successfully;
- Report any concerns regarding the fax transmission to their Line Manager immediately.
Beechdale Health Centre
Message Taking Protocol
Introduction
This protocol outlines the Practice’s approach to ensuring that messages (including requests for home visits) are recorded and acted upon by the appropriate team member.
Protocol
•LISTEN CAREFULLY AND SPEAK SLOWLY and ensure you inform the caller of your name.
•Remember that you are responsible for any messages you take until you have passed them on appropriately and with adequate information.
•Incomplete messages are annoying and potentially dangerous. The minimum information required when taking a message is:
Date and time the call/message was received
Your name
The caller’s identity (including organisation, if appropriate)
The patient’s identity (if appropriate). Verify the patient details by asking for at least one other piece of information, e.g. address, date of birth. You may need to check that the patient is registered before proceeding
The identity of the intended recipient
A contact telephone number – READ THIS BACK TO THE CALLER BEFORE HANGING UP
A brief but informative message
•All messages for Doctors, Nurses and admin staff are to be recorded by using the message books provided by each telephone station.
These message books also provide a duplicate copy of each message taken.
If the message is urgent, the intended recipient should be notified immediately by either telephone or by instant messaging
•Always verify that the person you are taking the message for is available, (e.g.they are not out of the surgery or on a half day or holiday).
•Messages relating to patients who require urgent attention must be passed to the Duty Doctor
•In the event the message relates to a patient and requires a telephone response, this is to be dealt with according to Practice procedure and the patient/caller must be advised of the approximate time the doctor will phone them back.
Details taken must include the patient or caller’s telephone number (home, work or mobile) and a brief description of the reason for their call.
•If a work’s telephone number is given, also ask for an extension number and confirm with the caller that they are able to accept calls at work
Security of the Message Books
All message books are dated with start date and finish date and the allocated desk site.
When a message book has been fully used, it is to be filed in the lockable archive stockroom for 3 years, as these duplicate messages hold personal information.
Beechdale Health Centre
Guidance for TRANSPORTING personal information
Beechdale Health Centre
Guidance for SHARING personal information BY POST
Beechdale Health Centre
Guidance for SHARING personal information BY PHONE
Beechdale Health Centre
Guidance for SHARING personal information BY FAX
Doc. Ref – Version – Filename: Safe Haven Protocols & GuidancePage 1 of 19
Beechdale Health Centre
Appendix A - Log Sheet to Record Collection of Prescriptions by Pharmacies
PHARMACYNAME: / LOG SHEET No.
Date
Collected / Date on
Prescription / Patient Name / Patient’s
D.O.B. / No. Items on
Prescription / Pharmacy Collector’s
Signature / Practice Staff
Witness Initials
Beechdale Health Centre
Appendix B - Log Sheet to Record Collection of Prescriptions by Nursing Homes
NURSING HOMENAME: / LOG SHEET No.
Date
Collected / Date on
Prescription / Patient Name / Patient’s
D.O.B. / No. Items on
Prescription / Nursing Home Collector’s
Signature / Practice Staff
Witness Initials
Doc. Ref – Version – Filename: Safe Haven Protocols & GuidancePage 1 of 19