B1 An OHS must maintain adequate occupational health clinical records No Standard Evidence Notes B1.1 An OHS must ensure that occupational Internal or external notes audits are aligned The representative sample size health clinical records, wherever held, are to the CSP core standards 2005 or to the must reflect the size and type of maintained to standards meet legal ACPOHE records procedure (modified for OH the service e.g. single or multi-site and regulatory compliance and professional from the CSP core standards and detailed in structure. The audit approach can practice recommendations the registered membership pack). be a monthly audit of records (e.g. A system of internal or external clinical audit 10 per month) or six monthly with or peer review performed within the last 12 a larger sample size (e.g. 50-100). months. The audit should cover a representative sample size of occupational health clinical records and assess whether entries are legible and documented in such a manner that they cannot be erased, are dated and signed or otherwise identified with the name of the author. B1.2 An OHS must ensure there are clearly A policy or documented procedure for It is advisable to have one core IT defined arrangements for backing up managing the risks associated with clinical policy that covers all standards computer data, back-up verification and a records in all media, which includes a relating to IT requirements, which safe back-up system. description of the; duties and legal can then be cross-referenced to obligations that apply to records, process for the relevant standard. creating, tracking, retrieving and backing-up It is essential for OH services with records, process for retaining and disposing OH IT records systems to have an of records, process for monitoring agreed statement between the compliance with all of the above. provider and the organisation Documented evidence of checks of regarding how this information is understanding of the process. backed up. Staff records must demonstrate understanding of the process. This can be checked on an annual basis at appraisal or via a training intervention. B1.3 An OHS must ensure that procedures exist The OHS has a documented policy for SLA as evidence of how clinical for the transfer of clinical records on transferring data in case of a transfer of records are managed between change of contract or closure of business services. physio and third party. Where a The transfer process is included in contracts transfer has taken place, with purchasers. demonstration that each party involved had a nominated individual responsible for the transfer process
B1 An OHS must maintain adequate occupational health clinical records No Standard Evidence Notes B1.1 An OHS must ensure that occupational health clinical records, wherever held, are maintained to standards meet legal and regulatory compliance and professional practice recommendations Internal or external notes audits are aligned to the CSP core standards 2005 or to the ACPOHE records procedure (modified for OH from the CSP core standards and detailed in the registered membership pack). A system of internal or external clinical audit or peer review performed within the last 12 months. The audit should cover a representative sample size of occupational health clinical records and assess whether entries are legible and documented in such a manner that they cannot be erased, are dated and signed or otherwise identified with the name of the author. The representative sample size must reflect the size and type of the service e.g. single or multi-site structure. The audit approach can be a monthly audit of records (e.g. 10 per month) or six monthly with a larger sample size (e.g. 50-100). B1.2 An OHS must ensure there are clearly defined arrangements for backing up computer data, back-up verification and a safe back-up system. A policy or documented procedure for managing the risks associated with clinical records in all media, which includes a description of the; duties and legal obligations that apply to records, process for creating, tracking, retrieving and backing-up records, process for retaining and disposing of records, process for monitoring compliance with all of the above. Documented evidence of checks of understanding of the process. Staff records must demonstrate understanding of the process. This can be checked on an annual basis at appraisal or via a training intervention. It is advisable to have one core IT policy that covers all standards relating to IT requirements, which can then be cross-referenced to the relevant standard. It is essential for OH services with OH IT records systems to have an agreed statement between the provider and the organisation regarding how this information is backed up. B1.3 An OHS must ensure that procedures exist for the transfer of clinical records on change of contract or closure of business The OHS has a documented policy for transferring data in case of a transfer of services. The transfer process is included in contracts with purchasers. SLA as evidence of how clinical records are managed between physio and third party. Where a transfer has taken place, demonstration that each party involved had a nominated individual responsible for the transfer process
SEQOHS%20Evidence%20Guide%20V1%204%20-%20physio-led%20services%20ACPOHE%20guidelines%20version%20(2).docx