Documentation and triage
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Mark, can you explain to me what documentation and how important the documentation is in the triage process and what sort of documentation you actually complete?
So where I work, the documentation is all digital. It is all recorded on the computer, the vital signs and the triage process and that stays with the patient's record for their life. So that is this hospital. Different trusts, different hospitals have different ways. Some hospitals are completely digital and they prescribe with IT and all the records are digital.
In some hospitals, the triage process is digital, but the patient care journey is all recorded in longhand and written on paper. The only thing, where I worked, that is not written down in terms of triage on the computer is when a mental health patient comes in and they are suicidal and you have to write a description of them, that is done as a pro forma and that follows the patient as well. Whoever is looking after the patient has that mental health pro forma. So it has got a description of them, what they are wearing and really, it needs to be done when the patient comes into the hospital because they may abscond at any point, people with mental health. But the important thing about documentation is that if you do anything freehand, you sign it and you date it and you stick to the facts.
This is all confidential patient information, so I'm presuming it has to be stored securely in a safe area. It is only between you and the patient and it should not be for prying eyes to see. So we have to make sure that laptops are closed and locked down and that all the processes are followed.
It is really easy to lock your screen, turn your screen off on the computer and walk away and that is what we should be doing.
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