Policies and Procedures

Document title
Document summary
What you can/cannot do with email and internet usage Clarify the Trust’s policy regarding use of the Internet and e-mail for work and personal use Avoid security threats by promoting awareness and good practice Encourage effective and positive use of the Internet and e-mail Protect the Trust against potential liability
Clinical Coding Policy v 3.0 (No access)
8458
The aim of the clinical coding policy is to provide accurate, complete, timely coded clinical information to support commissioning, local information requirements and the information required for Commissioning Minimum Data Sets and Central Returns.
This Code of Conduct sets out the confidentiality requirements for contractors who supply goods, services and/or consultancy to the Trust.
The purpose of the Confidentiality and Data Protection Policy is to lay down the principles that must be observed by all who work within the Trust and have access to personal information about either patients or staff.
Consent and Disclosure (No access)
12876
Guide to the sitiuations where patient consent for use of information is needed and where information may or must be disclosed.
This form is used to obtain consent from staff being filmed or photographed. A copy may be modified to suit the purpose. Copies of completed forms must be sent to Information Governance.
This form is used to obtain consent from staff being filmed or photographed. A copy may be modified to suit the purpose.Copies of completed forms must be sent to Information Governance.
Explains the process of Pseudonymisation
This document outlines the procedure for the issue and maintenance of Fallback and Short-term Access Smartcards at Barnet & Chase Farm Hospitals NHS Trust (BCFH). It is to ensure that all fallback and short-term access smartcard usage is correctly monitored and that adequate measures are taken to protect the National Programme for Information Technology (NPfIT) Spine applications from unauthorised access. This document is written to provide consolidated guidance on the production, issuance, and use of Self Service Fallback and Short-term Access Smartcards.
The Freedom of Information Act 2000 is part of the Government’s commitment to greater openness in the public sector, a commitment supported by Barnet and Chase Farm Hospitals NHS Trust. The Freedom of Information Act 2000 aims to transform the culture of the public sector to one of greater openness. It enables members of the public to question the decisions of public authorities more closely and ensure that the services we provide are efficiently and properly delivered
The Freedom of Information Act 2000 is part of the Government’s commitment to greater openness in the public sector, a commitment supported by Barnet and Chase Farm Hospitals NHS Trust. The Freedom of Information Act 2000 aims to transform the culture of the public sector to one of greater openness. It enables members of the public to question the decisions of public authorities more closely and ensure that the services we provide are efficiently and properly delivered
Barnet and Chase Farm Hospitals NHS Trust recognises the importance of effective health records management. It will ensure that all health records are created in accordance with this strategy and policy, readily accessible and available for use, and eventually archived or disposed of in accordance with national guidelines.
The Trust is committed to a systematic and planned approach to the management of Health Records within the organisation, from their creation to their ultimate disposal. This will ensure that the Trust can control both the quality and quantity of the information that it generates; can maintain that information in an effective manner; and can dispose of the information efficiently when it is no longer required.
To ensure that staff members safeguard all confidential information while traveling from one facility/location to another during the course of their working day. This may include confidential information contained within work diaries, notebooks, case papers, patient/client notes, Trust documents, ‘lap top’ computers etc.
IGTT Training Guidance (No access)
17530
Instructions for using the e-learning modules
Improving Data Quality (No access)
12166
The purpose of this document is to define good practice in all areas of patient related data, particularly to ensure that data collection is accurate, complete and timely to assure confidence in the Trust’s data.
Defines the terms of reference of the Information Governance Committee, including meeting dates and attendee roles
Document describing how the Information Governance Strategy is implemented at the Trust.
Local IG matters to supplement the generic IGTT e-learning.
Information Governance is a framework that brings together all of the requirements, standards and best practice that apply to the handling of personal information. It is therefore of paramount importance to ensure that appropriate policies, procedures and management accountability and structures provide a robust governance framework for information management. This policy contains the Terms of Reference for the IG Committee (formerly Steering Group)
This document defines the procedures to be followed for the recording of information incidents, their monitoring, review and mitigation of future risks by changes to actions and operational procedures.
This policy provides a framework for arrangements for the collection, processing and dissemination of information.
This document supports the Overarching Information Sharing Protocol and provides details of the operational procedures to be used for the sharing of information.
The purpose of this procedure is to instruct staff on what to do when they have patient casenotes that are ready to be archived. These casenotes are still within their retention period and may be called for if the patient re-attends Barnet & Chase Farm Hospitals NHS Trust for an appointment, admission or through a complaint or access to information request.
Multi Media - Recording Policy (No access)
17195
Policy ensuring that all audio/photography/video recording undertaken on Trust premises and of its patients and staff conforms to all current legislation, which provides patients and staff with rights of confidentiality, consent and protection against the unlawful processing of data.
NHS Number Procedure (No access)
14399
The Trust has developed a comprehensive strategy, action plan and Procedure for retrieving a verified NHS number that recognises the difficulty in allocating NHS numbers for certain categories of patients. The plan includes measures for routinely retrieving and recording the patient’s NHS number as near to the recording of their first contact with the Trust as possible, including where necessary use of NHS Demographics Services such as the NHS Strategic Tracing Service (NSTS), whilst this is operational, and the Patient Demographic Service (PDS).
This policy provides an overarching framework for the sharing of personal information about service users within and between agencies (e.g. NHS hospital services, primary care trusts, ambulance service, social services, education, mental health, etc.).
This describes to staff the actions they need to take when someone requests access to their own medical records.
PIA Guidance and Template (No access)
21058
Pseudonymisation Policy v1.1 (No access)
21056
Quick reference guide to the right way to send PID
Process for correctly transferring PID by fax
Process for creating Generic NHSmail Department accounts, including correct format of account email address
Guide to what you can or can not do with email and internet
How patients can access their own medical records
Guide for staff: what to do when a patient wants their medical records
Quick Reference Guide telling you how to update patient records
Guide for staff about sending text messages or leaving them on voicemail.
RA Policies and Procedures (No access)
21052
The Trust is committed to a systematic and planned approach to the management of Corporate records within the organisation, from their creation to their ultimate disposal. This will ensure that the Trust can control both the quality and quantity of the information that it generates; can maintain that information in an effective manner; and can dispose of the information efficiently when it is no longer required.
Safe Haven Fax Register (No access)
18053
Register of all Trust fax machines used to send or receive prsonal identifiable data (PID).
Safe Haven Procedure (No access)
11895
The National Health Service Management Executive introduced the concept of a Safe Haven as the focal point for controlling access to Person Identifiable Data (P.I.D) by fax. This document describes the rules that make such a location safe, as well as containing an appendix with all of the Trust approved safe haven fax machines.
The instructions to follow when scanning and emailing a document.
How to scan and email a document from colour Xerox devices.
A reminder to all staff on how to send confidential information via email, including a list of secure domains.
This is a flow-through document for staff who want to know how to send some personal identifiable data (PID). It asks a series of questions and as you answer you are guided through the document until you arrive at the correct solution
Smartcard User Guide (No access)
12038
The NHS Care Records Service Registration Authority is responsible for registering and verifying the identity of NHS staff that need to use the NHS Care Records Service and related IT systems and services, including Choose and Book and the Electronic Prescription Service (EPS). Access to these computer systems and services is controlled by smartcards with photographic ID and passcode, similar to a chip and pin credit card. Registration Authorities issues Smartcards to authorised staff with an approved level of access to patient information
Subject Access Procedure (No access)
8451
Patients have a right of access to health information about themselves. This procedure provides guidance on the processes to access both living and deceased patient records.
Systems Back Up Procedure (No access)
11899
To allow data essential to the business of the Trust to be restored or recovered as quickly as possible in the event of data loss or corruption on one or more of its computer systems.
The ppt presentation used for updating staff annually
ppt presentation used for Induction

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