Swslhd - Student e MR Policy for Students PDF

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This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students

Policy Directive

eMR - Access by Health Professional Students Document Number:

SWSLHD_PD2018_005

Functional Sub-Group:

Clinical Governance

Summary:

This Policy Directive outlines the process that SWSLHD must follow to facilitate student access to the eMR during clinical placements. This includes providing guidance to SWSLHD Health Professionals and clinicians on their responsibilities when directly supervising Health Professional Students who are on placement in our facilities/services/streams.

Approved by:

SWSLHD Clinical and Quality Council

Publication (Issue) Date:

January 2019

Next Review Date:

June 2023

Replaces Existing Policy:

N/A

Previous Review Dates:

N/A

eMR - Access by Health Professional Students Page 1 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students

Contents Review Process........................................................................................................................ 3 1.

Introduction........................................................................................................................ 4 The risks addressed by this policy:............................................................................. 4

2.

The Aims / Expected Outcome of this policy:.................................................................... 4

3.

Policy Statement................................................................................................................ 4

4.

Principles........................................................................................................................... 4 4.1.

Data Security and Privacy............................................................................... 5

4.2.

Supervision of Health Professional Students Accessing the eMR.................. 5

4.3.

Access to the eMR...........................................................................................6

4.4.

Documentation in the eMR by Health Professional Students..........................6

4.5.

Authenticating Student Entries........................................................................ 7

4.6.

eMR Training................................................................................................... 7

5.

Performance Measures......................................................................................................8

6.

Definitions and Acronyms.................................................................................................. 8

7.

References and Links........................................................................................................ 9

8.

Forms.................................................................................................................................9

9.

Attachments....................................................................................................................... 9 Attachment 1 – Required My Health Learning Modules for Completion by Health Professional Students............................................................................................... 10

eMR - Access by Health Professional Students Page 2 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students

Review Process Policy Author

District Clinical Information Manager

Policy Owner

Performance Unit

Policy Sponsor

Director, Finance

Stakeholders Consulted

      

SWSLHD eMR2 Subject Matters Expert (SME) groups (Nursing, Medical, Allied Health) SWSLHD Director of Medical Services SWSLHD Director Nursing & Midwifery SWSLHD Director Allied Health Nurse Manager, Clinical Informatics, Liverpool Hospital SWSLHD CEWD Clinical Analyst, IM&TD: SWSLHD.

Search Terms for Policy

eMR Access Students electronic medical records

Risk Rating

M

(SWSLHD Risk Matrix)

Approval Process Committee Name

Endorsement/Approval Date

Clinical and Quality Council

6 June 2018

Revision History Version

Amendment Notes

January 2019 Course codes amended in attachment 1. SWSLHD_PD2018_005 December 2018 Amendment to attachment 1. SWSLHD_PD2018_005 June 2018 Publication of policy directive. SWSLHD_PD2018_005

eMR - Access by Health Professional Students Page 3 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students

1. Introduction Health care organisations have a responsibility to ensure that Health Professional students receive experience in all aspects of clinical documentation. This policy outlines the standards and principles for student access to the eMR during clinical placements. Clinical documentation is an important skill that must be developed during the course of a Health Professional student’s education. In many clinical areas, the eMR will replace paperbased documentation of a patient/client’s presenting problem; history of illness; health care plan/s; health investigation and evaluation; diagnosis; care; treatment; progress; advance care directives; and health outcomes.

The risks addressed by this policy: 

Inadequate or inappropriate documentation about a patient’s condition and response to care can lead to a breakdown in communication that has the potential to cause errors or lead to adverse events. This could result in delays in treating complications and could adversely affect the outcome of a patient’s care.



Patient privacy and record security is compromised in the event of inappropriate use of the eMR by Health Professional students and Supervisors.

2. The Aims / Expected Outcome of this policy: 

To provide clear guidelines on the provision and level of eMR access to Health Professional Students.



To provide clear guidelines on what Health Professional Students are allowed to document in the eMR and the associated authentication required by the supervising clinician.



To ensure that future Health Professionals have been adequately prepared in relevant aspects of clinical documentation prior to commencing employment in the workforce.



To provide clear guidelines on the responsibilities of supervising Health Professionals when students are documenting in the eMR.

3. Policy Statement Access to the eMR should be granted to authorised Health Professional students in accordance with the principles in this policy. Supervising Health Professionals should supervise Health Professional student documentation in accordance with the principles in this policy and NSW Health policy directive PD2012_069 Health Care Records - Documentation and Management. Access to the eMR and use of the information should be for ongoing patient care, access to the eMR for purposes other than ongoing patient care should be in accordance with the Health Records and Information Privacy Act 2002 and the NSW Privacy Manual for Health Information.

4. Principles This policy will be implemented at all facilities/services that have substantial clinical documentation projects implemented (e.g. eMR2, CHOC, eMeds). The policy will be activated three months after the completion of substantial clinical documentation projects (e.g. eMR2, CHOC, eMeds) to allow clinical staff time to become familiar with the eMR systems. Some disciplines may implement the policy sooner at the discretion of the Department Head or Service Director.

eMR - Access by Health Professional Students Page 4 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students

4.1. 

Data Security and Privacy

Staff must be aware of their obligations in relation to data security and privacy, and comply with the requirements of the following documents: 

NSW Privacy Manual for Health Information

 PD2015_049 NSW Health Code of Conduct 

Staff and students must not provide their eMR username and password to others; any inappropriate use of the eMR will be attributed to the username used to access the eMR.



Health Professional students must be supervised by SWSLHD health professionals while accessing and documenting in the eMR.



Health Professional students must not print or copy any document/information from the eMR.



Health Professional students must not use personal mobile devices to capture any image(s) of the eMR. This includes medical imaging and other diagnostic results.

4.2. Accessing the eMR

Supervision of Health Professional Students

All staff who are supervising students accessing the eMR: 

Must have access to the eMR.



Must have received training in the relevant eMR module/functionality being accessed by the Health Professional student.



Must be aware that they are responsible and accountable for what is documented by the Health Professional student in the eMR.



Must be aware of their responsibilities as a supervisor and adhere to relevant data security policies and privacy legislation when accessing the eMR.



Should ensure Health Professional students only access the eMR and use or disclose information contained in the record when it is directly related to their duties and is essential for the fulfilment of those duties.



Are responsible for checking and co-signing progress note type documentation in eMR undertaken by the Health Professional student to authorise that it provides an accurate account of the assessment; care planning; management/care/ treatment/services provided and response/outcomes; observation/s taken; and results.



Are responsible for highlighting areas of the student’s progress that need further development with the student and/or their facilitator. Where there are concerns about a student’s level of competence, this should be escalated appropriately.

4.3. 

Access to the eMR

All Health Professional students must complete an eMR Student User Access Request form including the Data Security Declaration prior to access being provided.

eMR - Access by Health Professional Students Page 5 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students



The eMR Student User Access Request form must be authorised by the delegated officer within each professional discipline: Undergraduate nursing and midwifery students:  eMR Student User Access Request forms will be provided to the relevant universities by South Western Sydney Centre for Education and Workforce Development (SWSCEWD).  The form must be authorised by the relevant RN supervisor at the ward/department in the facility/service the placement is undertaken. Medical students:  The form must be authorised by the Medical Administration department at the facility (or their delegate) or University Clinical School. Allied Health:  The relevant department head or student coordinator for the discipline must authorise and witness the eMR Student User Access Request form.



Completed and authorised eMR Student User Access Request forms should be emailed to [email protected]



Access requests for students will be actioned within 72 hours.



Each Health Professional student will be assigned a security access position and an appropriate designation according to their professional discipline.



Health Professional students who are also employees of SWSLHD must be provided with a separate eMR account and use that when they are on clinical placement.



University-appointed facilitators will not be given access to eMR.

4.4. Students

Documentation in the eMR by Health Professional

The following documentation can be undertaken by all Health Professional students: 

Progress notes



Updating the ward-based Electronic Patient Journey Board.



Documentation of observations (BTF), fluid balance charts, lines, tubes drains, assessments etc. (iView), risk assessments and other forms contained within the eMR.



Medication administration: when a student nurse is supervised in administration of medications, the supervisor and, when required, the second accredited witness will document the administration of medication under their own account/s, and must enter the student’s name as the person who performed the administration.



Diet orders (Speech Pathology students only).

Health Professional students will record this information using the same electronic forms as Registered Health Professionals. Pre-Interns (PRINT) are medical students in their final year of training. The following documentation can be undertaken by pre-interns under the direct supervision of a Medical Officer employed by SWSLHD:

eMR - Access by Health Professional Students Page 6 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students



Electronic Discharge Referrals (eDRS) that can be submitted for signature. A transfer of care summary completed by the PRINT student can only be signed as completed by their supervising Medical Officer.

Medical students in Mental Health facilities (inpatient and community) are able to document patient assessments and other relevant documentation in the progress notes. These entries must be verified by a Medical Officer employed by SWSLHD. Health Professional students are not permitted to complete the following in the eMR: 

Medication orders.



Medication history, allergies and adverse reactions.



Order diagnostic tests (e.g. X-rays).



Endorse diagnostic results or any access to message centre.



Register patients, create encounters and update demographic/encounter details.



Schedule/reschedule or cancel appointments.



Add/update problems and diagnoses.



Add/update alerts.



Order non-diagnostic orders (e.g. Diet [except Speech Pathology students]).



Allied Health and other non-medical consultations.

4.5.

Authenticating Student Entries

Entries by students involved in the care and treatment of a patient /client must be co-signed by the student’s supervising Health Professional. It is the responsibility of the supervising staff member to ensure that all student entries made have been authenticated at the end of each shift. Within the eMR there is functionality to authenticate/co-sign student entries. This functionality is available for: 

PowerNotes



Clinical Notes

Where there is no functionality to authenticate/co-sign a student entry, a corresponding entry in the patient’s progress notes must be made by the supervising staff member to indicate that the student’s documentation has been reviewed and authorised.

4.6.

eMR Training

Students will be allocated a Stafflink number to access My Health Learning online two weeks prior to their placement start date. This number will be the student’s username to access eMR. Students must undertake the training outlined in Attachment 1 via My Health Learning online prior to their first clinical placement in a SWSLHD facility and eMR access being granted. All My Health Learning online training modules should be recorded on the student’s Training Transcript. Students are expected to retain appropriate documented information as evidence of competence. Access to the eMR will not be provided until all aspects of the student’s pre-placement requirements are met.

eMR - Access by Health Professional Students Page 7 of 11 PRINT WARNING- Printed copies of this document or part thereof should not be relied upon as current reference document. Compliance with this policy directive is mandatory.

This Document was accessed on: 01/07/2020 South Western Sydney Local Health District

Policy No.: SWSLHD_PD2018_005 Date Issued: 10 January 2019

eMR - Access by Health Professional Students

Additional information on eMR training resources (such as training videos, quick reference guides, access forms etc.) are available on the CST Intranet page http://swslhdintranet.sswahs.nsw.gov.au/services/ict/cst/studentaccess.html.

5. Performance Measures Annual audits: 

Clinical documentation audit is completed by the facility/service Clinical Information Departments; an additional annual clinical documentation audit is conducted by the District Clinical Information (in accordance with the District Clinical Information Quality Plan). The results of the audit and any associated recommendations must be tabled at the relevant facility/service committee and the SWSLHD Healt...