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Polly Esplen

The CQC and electronic patient records

When the CQC inspect and monitor a healthcare service there are five key areas they will look at:


  • Safety

    • "Helping ensure key information is accurate and easy to share with caring professionals in real-time"

  • Effective

    • Supporting effective communication and more efficient use of resources, including finances

  • Caring

    • Supporting person-centred care and helping staff to spend more time on the things that really matter

  • Response to peoples needs

    • Supporting providers to be more proactive and responsive to changing needs by helping to identify developing risks or needs more quickly

  • Well-led

    • Supporting more effective quality assurance through more effective communication, information sharing and improved data analysis



Here at The Care Database we have looked at each of these areas as stipulated by the CQC and have highlighted the areas where we can help. The following does not constitute advice and the original CQC guidance should always be the primary resource when evaluating these areas.



Safety


Patient safety is always our top priority. During a busy shift or visit, staff must be able to read and write care plans and notes easily and securely. To achieve this, we have:

  • All Information recorded in realtime.

  • An electronic notes tool with in-depth search functionality

  • Important data such as allergies are easily identifiable and accessible

  • A tool that is used by each organisation to create their own unique care plans

  • A system that is accessible on mobile devices.


Effectiveness


The most effective electronic care system will have the user’s processes at the heart of everything it provides. At each stage of development, we speak to our users to understand how they work. We can then deliver enhancements which streamline their daily tasks and ensure strong lines of communication.

  • Staff can share digital records quickly and easily

  • Use of handheld devices to record events as they happen - avoiding the need to complete paper records after the event has taken place.

  • Data generated in the database can be used to streamline invoicing, funding applications, timesheets and payroll.

Caring

We understand that care teams want to maximise the time that they spend with patients.

Because we listen, our technology supports staff, making procedural tasks easier and more efficient which gives them more time to care:


  • Technology can support staff to make their processes more efficient, giving them more time to care.

  • Digital records reduce the need for service users to have to repeatedly provide information.

  • Electronic notes are easy to input and read

  • Efficient search functionality identifies key information easily

  • Adaptable care plans provide clear and concise information that is relevant to the care provided by each individual organisation

  • Electronic archiving keeps historical information easily to hand


Response to people's needs


We recognise that a patient’s needs may change rapidly so we have included a number of tools to monitor the patient’s progress and help the team to provide appropriate care:

  • Scored assessments monitor whether areas of care show either improvement or decline.

  • Communication aids (such as tablet-based apps) can be tailored to an individual’s needs, preferences and activities. For example, they can be regularly updated with words and expressions that are important to the person using them.

  • Outcomes module can track a patients response to the specific care they receive.

Well-led


We include tools to help the senior team monitor the content of notes and care plans and ensure that clinical signoffs are completed where appropriate. These tools help to identify when it is appropriate for feedback to staff with additional training or to update internal procedures.

  • People who use services and their families can use online platforms to access and contribute to the information that is important to them. They can also communicate with those involved in their care and treatment.

  • Anonymised data collected can be shared, compared and analysed to identify risks and themes, providing a bigger picture.









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