OPERATIONAL PROCEDURES MATERNITY & … protocols and guideline… · MAT-SOP-001 Operational Procedures Maternity & Gynae Admin, ... 1.1.3.3 Appointments Call Centre . Job Title Admin

Author/ Reviewed Carole Brown / Ian Waddell Date: November 2017

Job Title Admin Services Manager/ Directorate Manager Mat & Gynae

Review Date: November 2019

Policy lead: Group Director Urgent Care Version: V4.0 ratified 3/11/17 Mat CG mtg

Location: Policy hub/ Clinical/ Maternity/ Professional guidelines/ MAT-SOP001

This document is valid only on date last printed Page 1 of 37

OPERATIONAL PROCEDURES

MATERNITY & GYNAECOLOGY

ADMIN, APPOINTMENTS & RECORDS

DEPARTMENT – (MAT-SOP001)

Approval and Authorisation

Approved by Job Title or Chair of

Committee

Date

Maternity & Children’s Services

Clinical Governance Committee

Chair, Maternity Clinical

Governance

3rd November

2017

Change History

Version Date Author Reason

1.0 Aug 2009 Lisa Glynn Trust requirement

2.0 Aug 2012 Tri-annual review due

3.0 April 2015 C Brown, L

Rough, J Sangha

Trust Admin Review

changes

4.0 Oct 2017 Carole Brown, Ian

Waddell

Reviewed – minor changes

Reviewed by Carole Brown / Ian Waddell Date: November 2017




Location: Maternity CG Shared drive/ Professional guidelines/ MAT-SOP001


MAT-SOP-001 Operational Procedures Maternity & Gynae Admin, Appointments & Records Department November 2017

QUALITY PROCEDURE

1. Details the process of the day to day operational procedures within Maternity &

Gynae Admin, Appointments & Records department.

Prepared by: Lisa Glynn

Date of first issue: August 2009

This version checked by: Carole Brown (Admins Services Manager) & Ian Waddell

(Directorate Manager Mat & Gynae)

Signature/date:

Signature/date:

This version authorised by: (Gill Valentine, Director of Midwifery)

Signature/date:

Location of copies:

Location of Copies No of copies

1 Quality Manager 1

2 File copy (electronic-Policy Hub) 1

Document review:

Review date Reason for Review Reviewed by Signature

Aug 2012 Tri-annual review due L Glynn

July 2015 Tri-annual review due C Brown

Aug 2017 Bi-annual review due C Brown/I Waddell

DOCUMENT AMENDMENT

Amendments may only be made on the electronic copy to ensure all formally issued

location copies are maintained to the updated requirements

Amendments (changes of up to a sentence in length) must be performed by senior

members of staff only.








Major changes (changes of greater than a sentence in length) must result in

immediate review of procedure.

No. Date Page

No

Amendment Authorised by:

1

SCOPE AND PURPOSE

1. Quality Management Procedures (QMPs) are formal authorised documents

detailing the procedures to be followed in the accomplishment of various tasks.

Note procedures may also be referred to as Standard Operational Procedures

(SOPs).

2. This QMP describes the day to day operational processes within Maternity &

Gynacology Admin, Appointments & Records department.

Document control Document control is an essential part of a quality management system.

A robust system for the regular review and updating of all guidelines, protocols, policies

and procedures has been agreed by the Maternity Clinical Governance Committee and is

monitored through this forum.








CONTENTS

MAD ORGANISATIONAL STRUCTURE 2014 ................................................................... 5

2.0 STAFF ....................................................................................................................... 9

3.0 ADMINISTRATION .................................................................................................. 10

4.0 ORGANISATION AND FACILITIES ........................................................................ 15

5.0 SUPPLY AND SERVICES ARRANGEMENTS ....................................................... 17

6.0 HEALTH AND SAFETY........................................................................................... 19

7.0 LOCAL TRUST POLICIES ...................................................................................... 20

8.0 QUALITY ................................................................................................................. 20

Appendix 1a - Standards for Outpatient Departments - Procedures for Maternity Outpatient Department .................................................................................................... 21

Appendix 1b - Standards for Outpatient Departments - Procedures for Maternity Outpatient Department .................................................................................................... 22

Appendix 1c - Standards for Outpatient Departments - Procedures for Maternity Outpatient Department .................................................................................................... 23

Appendix 1d - Standards for Outpatient Departments - Procedures for Maternity Outpatient Department .................................................................................................... 24

APPENDIX 1E - PROCESS FLOW NEW ELECTRONIC MATERNITY BOOKING SYSTEM ............................................................................................................................ 25




Appendix 3b - Standards for Outpatients Departments - Procedures for Maternity Outpatient Department .................................................................................................... 30

Appendix 4a - Standards for Outpatients Departments - Procedures for Maternity Outpatient Department .................................................................................................... 31


Appendix 4c - ORDER FOR INFORMATION WITHIN PATIENT’S RECORD ................. 33

Appendix 5 - Antenatal Clinics Consultant New Appointments - PATIENT FLOW 34

Appendix 7a - FIRE EMERGENCY PROCEDURE – ‘A’ FLOOR – PART 1 .................... 36

Appendix 7b - FIRE EMERGENCY PROCEDURE – ‘X’ FLOOR – PART II .................... 37








CAT 6 ORGANISATIONAL STRUCTURE 2017

Maternity Unit

(+ Gynaecology Appts

& Receptions)

SM – 1 x Band 7

(1.0 wte)

1 x Band 5

Deputy PPM

(1.0 wte)

PPM

3 x Band 4

(2.6 wte)

APPC

17 x Band 3

(15.0 wte)

Audit & Filing Clerk

Band 2

(2.0 wte)

Maternity Information

Officer

1 x Band 4

(0.6 wte)








1.0 SERVICE

1.1 Service to be provided by the Department

1.1.1 Main Maternity Reception Desk

i) Directing patients and visitors to the wards and departments.

ii) Access CMIS system to ascertain which ward a patient is on.

iii) Act as reception for official visitors/staff.

iv) Answer the phone for general enquiries and requests for notes.

v) Sorting mail

vi) Check patients out of clinic on EPR appointment system and arrange

follow-up appointments using ‘To be Scheduled’ List as required.

vii) File antenatal notes throughout shift onto antenatal shelves so that boxes

are empty at end of day.

viii) Print pulling Lists from EPR and pull Clinic Notes for next week’s clinics. All

clinics pulled 6 days ahead.

ix) Track all notes as appropriate using EPR HIM tracking application.

x) Maintain patient confidentiality at all times including ensuring any identifiable

patient information on desk is not viewable by visitors. All notes on desk to

be face down at all times.

1.1.2 Clinic Reception

i) Provide Local Reception desk service for all new and follow-up patients

attending the antenatal and gynaecology clinics. This includes Fertility

Clinic, Maternity Ultrasound Dept., and Antenatal Clinic & General Gynae

Clinic. Follow Reception Guidelines and Processes for each individual

Reception Area.

ii) Demographic details are checked and updated as required at check-in on

EPR for every patient. (please refer to EPR SOP OPD 13)

iii) Book new, follow-up and diagnostic appointments as requested by clinical

staff in each clinic. (refer to EPR SOPs OPD 06a, OPD 06b, OPD 06c, and

OPD 16)

iii) Co-ordination of appointments for induction of labour with the midwives.

iv) Receptionist responsible for check out of patients if not completed by Clinician. (refer to EPR SOP OPD 14)

v) End of Day Process for Each Clinic. Ensure all patients are outcomed on

EPR. Follow local procedures for DNA’s. (refer to: - Maternity ANC Patient DNA Policy and EPR SOP OPD 09)

vi) Update or add details to CMIS as appropriate.








vii) Reschedule appointments as appropriate following telephone requests from

patients, midwives, doctors etc.

viii) Track all Maternity and Acute Notes as appropriate.

1.1.3 Back Office

1.1.3.1 Antenatal

i) Preparation of all maternity records. Including making up new notes,

retrieving notes from off-site storage, amalgamating previous pregnancy

notes with new bookings. Repairing or replacing files if necessary. Create

media on EPR and print bar-code labels for new notes. Track notes on EPR

HIM tracking if appropriate. Prepare and collate notes for Nuchal Scans.

ii) Retrieval and filing of records, including merging of hand-held patient notes

& Postnatal Booklets. This will include Antenatal Notes (stored

alphabetically) and post-natal notes (stored by terminal digit filing)

iii) Retrieval of acute hospital notes for first visit, and for subsequent

appointments if indicated by the consultant.

iv) Ensure notes are stored securely.

v) Co-ordination of all paper antenatal documentation. Appendix 1a.

vi) Management of Community Electronic Bookings. (refer to CMIS Electronic

Bookings Process Document – Appendix 1e)

vii) Delivery of notes to ward areas on request.

viii) Ensuring all notes are available for Antenatal clinics, including Spokes, and

the Ultrasound Department Clinics.

ix) Update demographic details on EPR, and on notes as

required. Appendix 3a.

x) Identify overseas visitors and inform Overseas Department.

Appendix 4a 4b.

xi) Manage all new and follow up appointments. Appendix 1a 1c 1d.

xii) Manage all new and follow up appointments for Ultrasound Scan.

xiii) Manage all follow up appointments for joint Antenatal Diabetic clinic and joint

Antenatal Cardiology Clinic.

xiv) Procedure for patients who do not attend. Appendix 2a.

xv) Maintain the system for archiving records for women following miscarriage,

ensuring no inappropriate clinic letters are sent out.

xvi) Monitoring of available appointment slots and liaison with

Consultants regarding scheduling of the appointments.

xvii) Collation of statistics and activity.








xviii) Undertake daily housekeeping activities on CMIS including running daily

reports for coding etc.

1.1.3.2 Gynaecology

i) Receive and action all referral letters. Appendix 1b.

ii) Assist Gynae Staff in obtaining all notes for the clinic, liaising with Central

Medical Records Team, Gynae Secretaries and Waiting List Officers.

iii) Manage all new and follow up appointments. Appendix 1b.

iv) Procedure for patients who do not attend. Appendix 2b.

v) Update demographic details on EPR and in the notes as required.

Appendix 3b.

vi) Monitoring of available appointment slots and liaison with

Consultants regarding scheduling of the appointments.

vii) Collation of statistics and activity as required.

viii) Manage Choose & Book referrals and all national outpatient

targets including RTT pathways for patients.

ix) Assist ASM with booking Cancer 2ww referrals, communicating with patients

and Cancer Referral Team.

1.1.3.3 Appointments Call Centre

i) Book Nuchal Scans for all patients. Liaise closely with Ultrasound Scan

Manager for those patients where scan slot is not available within gestational

deadlines.

ii) Use Choose & Book System alongside EPR to book all Gynae first

appointments including diagnostic scan appointments. Currently using

indirect C&B booking.

iii) Book all Parent Education Classes for Mums on the PETS Access

Database.

iv) Deliver Baby Blood Spot test envelopes to Pathology every day by deadline.

v) Reschedule appointments from patient telephone requests.

vi) Sort Gynae Referrals once triaged by Consultant. Make any changes

requested by clinicians, e.g.:- book diagnostic scan. Update C&B if

necessary.

vii) Deal with all appointment requests from Gynae Secretaries, Wards etc.








1.2 Hours of Operation

1.2.1 Maternity Records/Back Office

08.00 – 17.00 Monday – Friday excluding Bank Holidays.

1.2.2 Reception Desks

08.00 – 17.00 Monday –Friday excluding Bank Holidays.

(Ultrasound Scan Reception will be manned to 18.00 hrs wherever possible)

1.2.3 Appointments Call Centre

09.00 – 17.00 Monday – Friday excluding Bank Holidays.

2.0 STAFF

2.1 Budgeted establishment of Staff 16/17

1.0 wte Band 7 Service Manager

1.0 wte Band 5 Deputy Patient Pathway Manager

9.12 wte Band 4

15.5 wte Band 3

2.0 wte Band 2

2.2 Training

2.2.1 Requirements for Staff

2.2.1 Induction Programme

i) Orientation and basic procedure training given by Admin

Services Manager, Team Leader & designated ‘buddy’.

ii) Trust induction day is arranged for all new staff.

iii) Induction programme is available for each employee

2.2.2 Mandatory Training

All staff are required to attend Trust Mandatory training.

2.2.3 Computer Training

i) EPR training is given by the Trust’s IT Training

Department. Registration, Enquiries & Appointment system.

ii) CMIS training is also provided, e.g. Registration,

Booking, Enquiries, and Label Printing.

2.2.4 Customer Care

i) All staff should attend a customer care programme.

ii) Regular updating should also be available.








3.0 ADMINISTRATION

3.1 Information Collection

3.1.1 Information is obtained from:

a) Letters

Letters are received from GP’s, Community Midwives and other

Departments within the hospital or from outside the hospital.

i) Referrals for Gynaecology Clinic.

ii) Referrals for Antenatal Clinic.

iii) Referrals for Maternity Ultrasound Scan Department.

iv) Referrals for Fertility Clinic.

b) Telephone Requests

i) Gynaecology Clinic appointments.

ii) Antenatal Clinic appointments.

iii) Maternity Ultrasound Scan Department.

c) Patients

i) Demographic information.

ii) GP details

iii) Date of Birth

iv) Ethnicity

v) Maternity Booking Information

Information is used for:

a) Statistics

i) Number of new patients per speciality.

ii) Number of new patients per Consultant.

iii) Number of follow up patients per speciality.

iv) Number of follow up patients per Consultant.

v) Waiting times for first appointment – Gynaecology only.

vi) Maternity PbR reports

vii) National Maternity Minimum Data Set.

viii) CQUINS

b) Identify patient’s hospital number/allocate patient’s hospital number

c) Medical Records

Antenatal

i) Preparation of new notes.








ii) Retrieval and merging of existing Maternity notes.

iii) Registration and booking on EPR and CMIS.

iv) Retrieval of acute hospital notes.

v) Merging of handheld patient notes after discharge.

Gynaecology

i) Request retrieval of medical notes from main medical records.

d) Appointments

Antenatal

i) GP/Midwife booked patients

ii) Consultant booked patients following prioritisation by Consultant.

Gynaecology

i) Information contained in letter is used by Consultants to prioritise

appointments.

Fertility

i) Fertility letters (new patients)

Overseas Visitors

i) All booking forms for potential overseas visitors are faxed to the

Overseas Visitors Department.

ii) The booking form is processed and the Overseas Visitors

Department are informed of the patient’s appointment date and

time of appointment and for Maternity Patients the EDD.

3.2 Maternity Records

This section should be read in conjunction with the Trust’s ‘Health Records

Management Policy’ CG059 on the Trust Intranet.

3.2.1 Antenatal

i) Current Maternity Records are stored in the Maternity Records Office. A

secondary store on X floor (Maternity Unit) stores 3 years of past notes.

All other notes up to 25 years of age are stored off site in the Trust

acquired storage facility.

ii) For each new pregnancy a pre-printed 7-part maternity notes pack is placed into a pink two spine folder. Each divider is clearly marked with information required for that section. On the inside cover of each file, the order for information is clearly indicated. (see Appendix 4C)








Maternity notes for previous pregnancies are requested from store. The

information inside these notes are re-filed at the back of the notes, and a

new maternity pack is inserted at the front.

All patients carry handheld notes throughout the pregnancy which are made

up by the midwife and kept by the patients until she delivers. These are then

sent back to medical records for them to file with maternity notes. All

mothers are then given a post-natal booklet which they keep with them until

discharged into the care of the Health Visitor. The midwife returns these

postnatal notes to the Maternity Records office. a record is kept by each

Community Office for postnatal notes which have not been returned, and a

list is provided to each midwife who has overdue records to be collected.

The Maternity Records Office then files the handheld notes into the hospital

maternity records. Any Notes received which belong to other hospitals are

logged and returned to the relevant hospital’s Maternity Unit.

iii) Acute hospital notes are requested for all new patients – this is done automatically via the EPR system and arrive for clinic 2 days in advance. Consultants will decide after the first appointment whether the acute notes are required for all subsequent appointments and are then stored in the department. If acute notes are not required for future appointments, they are returned to medical records department.

Decision is documented in the maternity records by the medical staff.

iv) Current maternity notes are ‘pulled’ for clinics and ultrasound approximately

one week before the clinic date.

v) Following the clinic, follow up patient’s records are returned to the Maternity

Records Department for filing. New patient’s records go to the relevant

Consultant’s secretary for letters to be dictated and are then returned to

Maternity Records for filing. Acute notes no longer required are returned to

the Hospital Medical Records Filing Department using the Trust Notes

Tracking system as protocol.

vi) If a patient attending the clinic has an induction of labour or a Caesarean

section booked, the records are taken by clinic staff to Delivery Suite or the

Antenatal Wards. The clinic staff are responsible for informing Maternity

Records that the notes have been taken to the relevant department and that

tracking of the notes takes place on EPR.

vii) Patients attending the clinic or ultrasound who required the services of the

Emergency Pregnancy Clinic on Sonning take their maternity notes with

them. Subsequently, the records are sent to the relevant Consultant’s

Secretary for letters to be dictated and are then returned to Maternity

Records for filing either in Maternity Records Department or in secondary

store, depending on outcome.








viii) Current maternity records are ‘pulled’ for satellite clinics, i.e. Wokingham and

Newbury.

ix) Newbury Antenatal Clinic: The records are all stored in Maternity Records

at the Royal Berkshire Hospital. 5 days before the clinic the notes are

‘pulled’ and placed in a designated green bag for transportation to Newbury.

2 days before the clinic the notes are sent to Newbury via hospital transport.

Following the clinic the notes are sent back to the Maternity Unit for letter

dictation/filing.

x) Wokingham Antenatal Clinic: The records are all stored in Maternity

Records at the Royal Berkshire Hospital. 5 days before the clinic the notes

are ‘pulled’ and placed in a designated blue bag. Notes for ultrasound and

the clinic are taken to Wokingham by hospital transport the afternoon before

the clinic. Following the clinic the notes are sent back to the Maternity unit

via hospital transport for later dictation/filing.

xi) Diabetic Antenatal Clinic: The records are all stored in Maternity Records

at the Royal Berkshire Hospital. The clerk responsible for this clinic pulls the

notes 2 days in advance, ready for the clinic on the appropriate date.

Following the clinic the notes are returned to the Maternity Records

Department for filing.

xii) If a woman has a miscarriage and attends Sonning, the Maternity Records

Department are notified, staff then code the records appropriately prior to

filing them in the secondary store.

xiii) Routinely other departments within the Trust request maternity records.

These are then pulled and sent to the relevant department. EPR will be

completed with the relevant tracking information.

xiv) Notes are requested by staff on antenatal wards and Delivery Suite.

These are pulled by Maternity Records staff, ward clerks or porters

out of hours in the absence of a ward clerk, and taken to the relevant

department. If the woman is discharged home, the notes are returned by

the ward staff to Maternity Records for filing.

xv) After delivery, when the woman is transferred home, the records go to

Coding first and are then returned to the Maternity Records Department and

placed in a designated box for postnatal notes.

xvi) All postnatal notes are then archived on CMIS by maternity records staff.

The notes are then sent to the secondary Maternity Records store on X floor

for filing, following tracking.

xvii) If a woman has a termination for foetal abnormality, stillbirth or neonatal death, following delivery the notes are either retained on Delivery Suite for collection by the clinic midwife designated co-ordinator for bereavement or are sent to Pathology for the post mortem of baby over 24 weeks’ gestation.








These notes are returned either to the Consultant’s secretary and then to co-ordinating midwife or directly to the midwife. Notes are kept in the Maternity Outpatient Department until the patient has been seen in the bereavement counselling session by the Specialist Consultant Obstetrician. Following this, the records to the Consultant’s secretary for a letter to be dictated and are then returned to Maternity Records for postnatal filing.

xviii) Frequently other departments within the Trust in addition to staff within the

Maternity Unit request postnatal notes. These would be pulled and sent to

the relevant department, updating tracking at all times.

xix) Occasionally other agencies outside the Trust request access to postnatal

notes. Once access has been agreed, either Maternity Records staff or the

outside agencies pull the notes required and file them after use.

xx) The records of those patients who Do Not Attend (DNA) for their antenatal

appointment are sent to Maternity Records for filing. Further appointments

are arranged as requested by midwives or clinical staff.

xxi) All maternity records must be tracked on EPR at all times.

xxii) Maternity records MUST NEVER LEAVE THE HOSPITAL SITE. If a patient

moves out of the area and her doctor/midwife request notes held at the

Royal Berkshire Hospital, a photocopy is made and sent to the appropriate

professional via a formal request made to the Consultant Obstetricians.

xxiii) If a patient requests access to her health records or requires specific

information from her notes, this request has to be made in writing to the

Central Medical Records Manager and a fee is charged for the notes to

be photocopied.

3.2.2 Gynaecology

i) Gynaecology records are stored in the main medical records store.

ii) Notes required for a clinic are requested one week in advance.

iii) Gynaecology records are sent to the Gynae clinic co-ordinators office

for preparation for the clinic.

iv) Notes required for the clinic which are missing or requested late are

tracked by the clinic notes specialist who is based in Maternity Outpatients.

v) After the clinic the notes are sent to the relevant Consultant’s secretary for

letter dictation and/or to provide information to enable patients details to be

placed on waiting list.

vi) The medical secretaries are responsible for sending the records back to

the main Medical Records store. Each set of notes is tracked on the EPR

system back to Medical Records store.

vii) Should the Consultant request an ultrasound scan as part of his consultation, the records would be taken with the woman to the scan department and returned with the patient to the clinic following the scan.








The notes will be placed in a sealed transit bag before the patient takes them to the Scan Department. This bag is re-sealed on returning to clinic.

viii) If a patient requires admission to a ward directly from the clinic, the notes

go with her to the ward, again in a sealed transit bag.

ix) The records of those new patients who Do Not Attend (DNA) their

appointment are dealt with following the Patient Access Policy. Patients will

either be booked another appointment and their notes retained for that

appointment, or discharged and the notes tracked back to central medical

records.

3.3 Financial Systems

3.3.1 Stock Ordering

i) A designated member of the Maternity Records team is responsible for

ordering stock items via Oracle.

ii) Stock items are ordered as required – no regular order is placed.

iii) When the items are delivered they are checked against the picking ticket

provided by Office Depot and Lyreco.

iv) The picking tickets are kept until they have been checked by the

Maternity Records manager against the complement to budget holder’s

report which is produced monthly.

3.3.2 Non Stock Ordering

i) The Admin Services Manager is responsible for ordering non stock

items via Oracle.

ii) When the goods have been delivered, the Goods Received Note is then

signed by another designated member of staff stating that the goods have

been received. This is then returned to the Procurement Department.

4.0 ORGANISATION AND FACILITIES

4.1 Patient flows – See appendices 10 and 11

4.2 Utilisation of each room/activity space

4.2.1 Main Reception

i) Enquiries desk for patients, visitors, relatives and others attending the

Maternity Unit.

ii) Appointment desk for women attending the antenatal, gynaecology and

ultrasound clinics.

iii) Incoming post for the Maternity Records Department and medical staff is

sorted and distributed.








iv) Phones are manned by Maternity Records staff. Calls taken include:

enquiries from patients and staff, requests for appointments, alteration of

appointments, requests for notes, information for GP’s and other staff

working in the community.

v) Primary maternity records store for current antenatal patients.

vi) Accommodation for four PCs – EPR and CMIS on each.

4.2.2 MAD Back Office

i) 7 work stations which involve computer points and telephone points. The clerks responsible for the gynaecology clinic, antenatal clinics and GP/MW

antenatal notes will be accommodated in this office.

ii) Call centre with 3 work stations with PC’s booking Choose and Book

appointments and other appointment queries.

iii) All antenatal, gynaecology outpatients’ administration is performed in this

office.

iv) Storage of maternity records which have been pulled for the following

week’s clinics.

v) Storage of new consultant booked patient records prior to first clinic

attendance.

4.2.3 Maternity Records Manager’s Office

i) 1 work station which includes computer points and telephone point.

ii) Accommodation and facilities for Admin Services manager.

4.3 Admission/Reception of Patient

4.3.1 Women requiring inpatient admission are directed to the relevant

ward/department.

4.3.2 All patients attending the antenatal, gynaecology or antenatal diabetic clinic are

directed to the clinic reception desk. Patients attending the ultrasound department are

directed to the ultrasound reception. Patients attending the fertility/family planning clinic

are directed to the fertility/family planning reception desk.








4.4 Discharge/Follow Up Appointment

4.4.1 Patients attending the outpatients department will be asked to make a follow up

appointment by the doctor if required. Follow up appointments can be made at

the appointments desk in main reception.

4.4.2 When inpatients are discharged home and require a follow up appointment, the ward staff

contact the Maternity Records department for an appointment to be made. The

appointment is given to the patients by the ward staff.

4.5 Interdepartmental Referral of Patients – where relevant.

4.5.1 The doctor writes a referral letter to the relevant consultant’s team within the

Trust.

4.5.2 All referral letters are prioritised as in section 1.1 above.

4.6 Interdepartmental Transfer of Patients

4.6.1 When antenatal patients are transferred to other departments, the maternity

records are sent to that department.

4.6.2 If an antenatal patient is transferred to another hospital outside the Trust, the

maternity notes are photocopied and sent with the patient. The original notes

always remain within the Trust.

5.0 SUPPLY AND SERVICES ARRANGEMENTS

5.1 Delivery and Collection of Post, Stores, and Patients notes, X-rays etc.

5.1.1 Post

i) Post for the Maternity Records Department is delivered by the portering staff

twice daily to the Maternity Records office and left in a designated basket.

ii) A member of staff sorts the post and distributes to the various departments in the

Maternity Unit. All post received is date stamped.

iii) Outgoing post is placed in a designated basket in the maternity records office for

collection twice daily.

iv) Post for Newbury and Wokingham Hospitals are placed in designated sealable

bags. The blue bag for Newbury is collected daily from maternity reception. The

bag for Wokingham is taken weekly to the hospital.

5.1.2 Stores

i) Stores are ordered as required.

ii) Stores are delivered from the main stores by the designated stores person.

iii) Delivery of stores is to maternity records office.








5.1.3 Patient Notes

i) Acute hospital notes are delivered to maternity records department by

designated medical records porter.

ii) Any missing notes or extras added to a clinic are collected from either medical

records or other departments by the clinic coordinator.

iii) Acute hospital notes are collected from maternity records and medical

secretaries’ offices by the designated medical records porter.

iv) Maternity records required by Newbury are collected from maternity records RBH

(in a green bag) by the transport department on a Monday, Tuesday and

Wednesday for the ultrasound and antenatal clinics.

v) Maternity records required by Wokingham ultrasound and antenatal clinics are

collected by transport on a Wednesday for these sessions.

vi) Maternity receptionists deliver maternity records to various departments within

maternity unit.

vii) Maternity records required by other departments within the Trust are delivered by

records porters.

viii) Postnatal notes required for audit etc. are pulled by the Central Medical Records

audit clerk.

ix) Notes are returned from Newbury in a green bag in hospital transport following

the clinic to maternity records, RBH.

x) Notes from Wokingham are returned in a bag via hospital transport to

maternity records RBH.

xi) Ward clerks on Delivery Suite and the postnatal wards are responsible for

returning postnatal notes to maternity records department.

5.2 Portering

As 5.1 above.

5.3 Housekeeping

Maternity reception, records office and maternity records manager’s office are cleaned

according to Trust’s agreed cleaning schedules.

5.4 Waste Collection and Disposal

5.4.1 Housekeeping staff empty waste paper bins each evening Monday to Friday.

5.4.2 Paper for shredding is collected in a security sack. When full, this is taken by a

porter to the secure designated area and left for shredding.

5.4.3 Paper for recycling is collected in a designated blue cardboard box. When full,

housekeeping staff empty.








5.5 Estates

5.5.1 All requests for repairs etc. are logged on the Facilities Webpage. Each area within

Maternity Unit has a Manual Log where reference numbers are recorded and

Estates staff can update when they carry out the requested maintenance.

5.6 Maintenance of Equipment

5.6.1 Estates department carry out all routine maintenance within the Unit.

6.0 HEALTH AND SAFETY

6.1 Risk Management

6.1.1 Each department has a nominated risk management officer responsible for that

area. This is the Team Leader.

6.1.2 Risk assessments are carried out as required and reviewed quarterly. All

assessment documents are available in the Green desk assessment folder

located in the Admin Services Manager’s office.

6.1.3 Security grills are in place around the main reception/enquiries desk.

6.1.4 Clinical incidents are reported via the Trust Clinical Incident Reporting Website.

6.2 Fire Precautions

6.2.1 All staff attend a Trust fire lecture annually.

6.2.2 Local fire procedure is located in the reception area and administration office. See

Appendices 13a and 13b.

6.2.3 Trust fire procedure is located in the reception area and administration office.

6.3 Security

6.3.1 The Primary (live) maternity records are located behind the main reception desk.

The secondary maternity records store (x floor) are kept locked at all times.

6.3.2 All the computers at main reception and in the administration office are also

security marked (engraved).

6.3.3 All staff are allocated a locker.

6.3.4 The security guards’ desk is located opposite the main reception area. The

CCTV monitors are situated here and allow the security guards to see all

the entrances and exits to the maternity unit. The main key cupboard containing

keys to every door on A floor is kept in Security. All guards carry a bleep.








6.5 Infection Control

Medical Records staff must comply with bare below the elbows and hand hygiene policies

when entering clinical areas.

7.0 LOCAL TRUST POLICIES

7.1 Patients Services Medical Records Standard Operating Procedure.

This document is available on the Maternity Intranet site.

8.0 QUALITY

8.1 Standards for Outpatient Department These are available as part of the Standard Operating Procedure document available on

the intranet.

8.2 Access to Notes

Notices are displayed in public areas informing patients of their rights with regard to access

to notes. All maternity records staff are aware of the procedure for access to health

records. A copy is displayed in the administration office.








Appendix 1a - Standards for Outpatient Departments - Procedures for Maternity Outpatient

Department

1. Date Stamping Referral Letters Any paper referral letters from General Practitioners and other health care professionals are

received by Maternity Admin staff and sorted into antenatal referrals and gynaecology referrals.

1.1 Antenatal

i) All letters are sorted according to consultant or GPMW and the letters are date

stamped using black ink. This must take place on the day that the letter is received.

ii) The number of letters received for each consultant is recorded on a spread sheet.

iii) The letters are given to a designated clerk to be registered on EPR and CMIS. This

must be completed within 5 working days of the letter being received. All

scan requests are then put into Scan Dept.’s basket to be collected daily ready for

women to ring the call-centre for their dating scan.

iv) All registration of women onto EPR must follow SOP OPD56

iv) Once the details are entered on EPR and CMIS the letters are given to the relevant

Consultant for prioritisation, which must be completed within 5 working days of

receipt of the letter.

Any generic referrals go to the consultant obstetrician for allocation and

prioritisation.

v) After prioritisation the letters are given to the clerk responsible for consultant

bookings. Those letters which required urgent appointments should be processed

first and the patient informed that day either by letter or telephone.

Appointment details must be sent to all patients within 10 working days of

receipt of the letter and should include the following information:

Hospital contact number

What to bring with them for the appointment

Parking facilities

Patient cancellation procedure

Did not attend procedure








Appendix 1b - Standards for Outpatient Departments - Procedures for Maternity Outpatient

Department

1.2 Gynaecology (paper referrals)

i) All letters are sorted according to consultant and the letters are date stamped using

black ink. This must take place on the day of receipt of the letter.

ii) The number of letters received for each consultant is recorded on a daily basis.

iii) The letters are then registered on EPR.

iv) The letters are then sorted according to consultant and are given to each consultant

for prioritisation. (All letters must be prioritised within 2 working days).

v) Following prioritisation, the letters are returned to the Call Centre Office where the patients appointments will be booked according to consultant’s instructions and appointment letter sent out to the patient.

1.3 Gynaecology (Choose & Book Indirect Bookings) i) When a patient telephones our call centre and books an appointment a pink C&B

form is completed. The referral letter is then run off of the system and attached to the pink form. The pink forms are taken to the relevant consultants on a daily basis for their assessment.

ii) The pink forms & referral letters are returned to the Maternity Admin Office. These will then be accepted on C&B and any amendments to the appointments made as per the consultants instructions on the form. Patients will be informed by letter of any changes that have been made to their appointment. If any are rejected by the consultant this is done on the C&B system and a standard letter sent to the patient asking them to contact their GP.

iii) The referral letters are filed in relevant consultant’s files in appointment date order ready for the clinics.








Appendix 1c - Standards for Outpatient Departments - Procedures for Maternity Outpatient

Department

2. Prioritisation of Generically Addressed Letters 2.1 Antenatal and Gynaecology

i) All letters received by the Maternity Admin Department for date stamping

and counting.

ii) Any generic paper referrals for Gynae are prioritised by any available consultant and then booked into first available appointment. The appointment date must meet any local and national targets in line with the patients 18 week pathway.

iii) All Gynae diagnostic tests must be booked within the 6 week target. Any problems

with meeting this target must be flagged up with managers so that appropriate steps can be taken to increase capacity if necessary.

iv) Obstetric generic referrals are allocated to a named consultant by one of the

Consultant Obstetrician who is responsible for checking through all generic referrals to ensure they are given appointments with the consultant with the relevant specialist interest and within specific gestational timelines.

2.2 Gynaecology 2 week wait Cancer Referrals

i) Every day on a regular basis throughout the day a clerk will take urgent referrals off of the C&B 2ww referral list.

ii) These referrals are collected by the Gynae ASM and appointments made in the relevant clinic within 2 weeks. All clerks are aware of the 2 week cancer target and understand these referrals are a priority. Several clerks are trained in checking the referrals and ensuring they go into the correct specialist clinic. Any concerns or queries are taken to the Admin Services Manager or to RV or AMC’s secretaries.

a) Any post-menopausal bleeding referrals go into SpR Clinic with a scan booked

15 minutes prior to clinic appointment.

b) Any ?cervical cancers go to colposcopy clinic

c) All other cancer referrals go firstly into the clinics of the Gynae Oncologists.

Any problems in getting patients into appointment slots within the 2 week target will

be flagged up to the Admin Services Manager. The referral letters are then filed in

the relevant files ready for clinics.

iii) Patients will be telephoned and given appointment over the phone if at all possible

as appointments are often booked at very short notice. All letters are sent first

class.








3. Prioritisation of Referral Letters in a Consultant’s Absence

i) In the event of a Consultant Obstetrician being on leave, their secretary will ensure another

consultant triages any referrals during the period of absence. If the Generic Referral

Triage Consultant is away, she will designate somebody else to cover this task,

ii) When Gynaecology consultants are absent, another named consultant will

prioritise on their behalf.

Appendix 1d - Standards for Outpatient Departments - Procedures for Maternity Outpatient

Department

4. Telephone Referrals

4.1 Antenatal

GP/Midwife booked patients who require an appointment to see a consultant are referred

by telephone by either GP or midwife. An appointment is made over the phone and a

GP/Midwife referral letter given to the patient to bring to the clinic.

Very occasionally it is necessary for unbooked women to be referred via the telephone. In

these circumstances the following procedure is used.

i) The clerk in the maternity records department completes a telephone

request form with all the relevant details.

ii) An appointment is made and these details are given during the phone call.

iii) Demographic details are entered on EPR and CMIS

iv) Hospital number is generated if not already registered following SOP OPD56

v) Telephone referral form is filed in the patient’s notes.

4.2 Gynaecology

The medical secretaries or Gynae Ward Clerks are the only clerical staff authorised

to make telephone referral appointments. Each secretary follows the same

procedure.

i) Patient details are completed on the telephone request form.

ii) Secretaries liaise with maternity record staff to make appointment.

iii) GP or other professional and patient contacted with details of the date and

time of appointment








APPENDIX 1E - PROCESS FLOW NEW ELECTRONIC MATERNITY BOOKING SYSTEM

CMW sends details of women

coming for booking, in advance, to

MAD Back Office via dedicated

bookings NHS.net e-mail account on

the form supplied.

rbb-tr.maternitybookings.nhs.net or

ring ext. 7425 for short notice

appointments.

(Out of Hours – if you need to do a

booking urgently out of hours and

need a patient registered ring A&E)

MAD Back Office will monitor

Bookings E-Mail account at

regular intervals throughout each

day.

Print off Booking Clinic Forms

and keep on file for cross

referencing.

Register patients on EPR.

Create

Hosp No’s if required. Check &

update demographics, GP

details and Contact numbers.

CMW sees patient in her Booking Clinic

Put booking information directly onto CMIS using Laptop.

Use either LAN cable to Surgery Broadband, Wi-Fi if

provided or CMIS via Terminal Server and 3G. If no

connectivity at all then revert to completion of a paper

based booking form and deliver to MAD back office as

usual.

For women delivering at

other hospitals.

Complete their booking form

and then just translate that

information into a booking for

the woman on CMIS.

MAD Back Office use Booking Clinic Lists each day to print off

Booking Forms from CMIS.

CMIS will print default of 3 copies of booking form – 1 for pink notes

and 2 to be given to woman at her first appt (nuchal scan in most

cases).

Print off 2 sheets of labels – 1 for notes and 1 to be given to woman

with her booking notes.

Cross reference all patients with booking information on CMIS. Any

consultant bookings – chase consultant referral form (e-mail or

basket) and tie up with printed booking form. Send to consultants

for triage as normal.

Make up Pink Notes as usual including requests to Crown

Make Scan Appointments

Make Consultant Appointments – update CMIS with correct Consultant

or GP/MW once referral comes back to office triaged.








Key: - CMW = Community Midwife MAD = Maternity Admin Dept.

LAN = Local Area Network. HV = Health Visitor

LA = Local Authority.

CMW sees patient at next appt and can use 2nd

copy of

booking notes in Bounty Plastic Wallet to copy for HV or

LA as needed. (When E-docs goes live this can be done

electronically direct from CMIS).

CMW at 10 Days PN (or other appropriate date).

Opens patient’s record on CMIS and use ‘Follow-Up’

button to discharge patient from Midwife Care. This will

archive current pregnancy and pull through into

Smoking, Breast Feeding and Blood Spot Screening

reports.

Patient Attends for First Appt.

Receptionist in Scan or Clinic will take patients hand held notes

from her. File 1 copy of printed Booking Form into booklet using

treasury tags. Place 2nd

copy and labels into plastic wallet for CMW

use at next appt.

WBCH Scan Clinic Sonographer will hand booking notes and

labels to patient to put in her wallet.









Department

5. Patients who Do Not Attend (DNA) - This should be read in conjunction with the

Maternity Guidelines on Patients Who Do not Attend in the Patient Access protocol

(CG499).

5.1 Antenatal New Attendances

5.1.1 The clerk responsible for consultant clinics or an ANC Midwife will telephone the

patient’s GP Surgery to ascertain whether or not the woman is still pregnant.

a) If the woman is no longer pregnant, the notes are passed to the

Maternity Admin Staff who then archive the pregnancy on

CMIS

b) If the woman is still pregnant another appointment (usually for the following

week) is sent to the patient’s address following discussion with one of the

ANC midwives

c) If after the second appointment the woman still DNA’s the notes

are given to the medical secretary to write to the GP informing him

that the woman has DNA’d twice and asking the GP to contact the

maternity records department if another appointment is required or

to inform us if the patient has moved.

d) The patient’s Community Midwife will be informed and asked to investigate.

5.1.2 An addressograph label is placed alphabetically in an A –Z book with the

date of DNA and action taken.

5.1.3 The clinic sheet is also marked DNA next to the patient’s name.

5.1.4 A record of the DNA and date is made in the patient’s notes.

5.2 Antenatal Follow Ups

5.2.1 The clinic sister informs the maternity records that a patient has DNA’d.

Another appointment is made.

5.2.2 Patient’s details and further appointment information is given to the

relevant community midwives’ office so that the community midwife can

visit the patient.

5.2.3 An addressograph label is placed alphabetically in an A-Z book with the

date of the DNA and action taken.

5.2.4 A record is made in the patient’s notes of the date of DNA.

5.2.5 The clinic receptionist marks the clinic sheet with DNA next to the

patient’s name.









Department

5.3 Gynaecology New Attendances

5.3.1 The clerk responsible for the gynaecology clinic writes in the notes that

the patient has DNA’d plus date and amends EPR.

5.3.2 Consultant is asked about whether a further appointment should be made,

referring to the Trust Access Policy if necessary. Notes are returned to the

relevant Consultant Secretary for Standard letter sent to GP of each patient

who has DNA’d stating that, if a further appointment is required, the GP

should re-refer the patient to the Department.

5.3.3 The clinic sheet is also marked DNA next to patient’s name.

5.4 Gynaecology Follow Ups

5.4.1 The clerk responsible for the gynaecology clinic writes in the notes that

the patient has DNA plus date and amends EPR.

5.4.2 The notes are given to the relevant medical secretary for the consultant to

decide whether or not a further appointment should be made. If another

appointment is to be made the notes are given to the Maternity Admin

Office for this to be done.

5.4.3 The secretaries write to the GP informing them that the patient has DNA.

5.4.4 The clinic sheet is also marked DNA next to patient's name.









Department

6.0 Checking Demographic Details on all Outpatient Attendees

6.1 Antenatal

6.1.1 All patients attending for their first or follow-up consultation appointment

report to the clinic reception desk.

6.1.2 The clinic receptionist checks that the name, address and GP details are

correct. If the address given is a temporary address, then details of the

permanent address are also recorded. Ethnicity is also checked with

each patient and recorded on EPR.

6.1.3 All new patients are asked if they have had any previous pregnancies at

this hospital to ensure that existing notes are available for the

consultation.

6.1.4 If any of the demographic details are found to be incorrect, details are

amended:

a) In the patient’s medical notes

b) On EPR

c) On patient’s appointment card

d) On Patient’s Handheld Notes

6.1.5 Existing addressograph labels are destroyed and new ones issued with

the amended demographic details

6.1.16 The front page of the Maternity Notes should be updated with new details.








Appendix 3b - Standards for Outpatients Departments - Procedures for Maternity Outpatient

Department

6.2 Gynaecology

6.2.1 All patients attending for their first or follow-up appointment report to the

clinic reception desk.

6.2.2 The clinic receptionist checks the name, address and GP details are

correct. If the address is a temporary address then details of the

permanent address are also taken. Ethnicity is also checked with each

patient.

6.2.3 If any of the demographic details are found to be incorrect details are

amended:

a) In the patient’s medical notes

b) On EPR

c) On patient’s appointment card

6.2.4 Existing addressograph labels are destroyed.

6.2.5 The front Demographic page of the Acute Notes should be updated.








Appendix 4a - Standards for Outpatients Departments - Procedures for Maternity Outpatient

Department

7.0 Overseas Visitors

7.1 If any Gynaecology referrals are received which indicate that a patient may not have

lived in the Country for 12 months a password-protected e-mail form is sent with the

patients details to the Overseas Department.

7.2 Antenatal referral information for either consultant or GP/Midwife booked patients is

checked by the clerks responsible for antenatal bookings.

7.3 If the records denote that the patient has not lived in the United Kingdom for the

past 12 months a password protected e-mail form is sent to the overseas visitors

department.

7.4 If the clerks are in any doubt about whether or not a patient could be considered an

overseas visitor, e.g. student, the overseas visitors department should be contacted

for advice.

7.5 When details of a patient have been given to the overseas visitors department, the

clerk must write this on the information sheet held in the hospital records.

7.6 Following investigation the Overseas Department fax us an eligibility form which

states whether or not the patient is entitled to free NHS treatment. This is filed in

the patients notes.









Department

8.0 Access to Maternity Record

8.1 Antenatal Notes

8.1.1 The maternity records staff are responsible for pulling all maternity

notes for the clinics held in the antenatal clinic and ultrasound clinic.

8.1.2 Any requests for notes from the delivery suite for ladies coming into labour are

requested by labour ward to maternity reception if there is no Ward Clerk on duty.

Labour Ward have 24/7 Ward Clerk cover but in the case of sick or annual leave

there may not be a clerk on duty. Some of these ladies will have been asked to pick

up their notes from reception. The receptionist will pull the notes from file and track

them. The notes will then be placed in a sealed bag with a security tag for the

ladies to collect.

8.1.3 This procedure is in place from the hours of 08:00 to 17:00 Monday – Sunday.

8.2 Out of Hours

8.2.1 The maternity reception is unmanned after 17:00 hours. Any requests for notes if

there is no Ward Clerk on duty will be dealt with by the Maternity Porters who will

take the notes up to the wards. The Ward Staff should then ensure these notes are

tracked on EPR asap.

8.3 Postnatal Notes

8.3.1 The maternity records staff deal with any postnatal requests. Notes required for

audit by doctors will be dealt with by the Medical Records Audit Clerks. We ask for

a reasonable time to be given to enable the postnatal clerk to collate the notes,

usually 7 days. Only 10 sets can be requested at any one time, if more are

required, the first ten should be returned before any further notes are pulled.

8.3.2 At no time should maternity records be taken from the maternity unit,

unless requested for a clinic or a consultant to view in another speciality.

8.4 Postnatal Notes (out of hours)

8.4.1 Any request for postnatal notes after 17:00 hours will be dealt with first

thing in the morning. Any old maternity notes that are stored off site will

be requested by fax the next morning.








Appendix 4c - ORDER FOR INFORMATION WITHIN PATIENT’S RECORD

Most recent information to be filed on top of the relevant section.

SPINE 1 (FRONT) SPINE 4

Alert (Flash) Sheet Pathology Mount Sheet

Consultant Referral Letter

Pink Referral form – 4 pages.

SPINE 1 (ON REVERSE SIDE OF SPINE) SPINE 5

Scan Sheet Correspondence

Consultant Planned Care (Green)

Antenatal Care Record (Yellow)

Antenatal assessment/admission (Yellow)

Manila Self-Seal Envelope “Antenatal CTG”

SPINE 2 SPINE 6

Admission for delivery Hand Held Notes

Partogram (blue)

Continuation Sheets (x4)

Manila Self-Seal Envelope “Intra-Partum CTG”

SPINE 3 SPINE 7

Consent Form Drug Charts

Anaesthetics record sheet

Epidural Chart

Caesarean section delivery record

Puerperium.








Appendix 5 - Antenatal Clinics Consultant New Appointments - PATIENT FLOW

Patient referred for consultant

antenatal care/booking

GP/Community Midwife

Prioritisation of referral/decision on:

- clinic appointment - scan - scan and clinic (one date) - scan and clinic (2 dates)

Consultants

Patient arrives at the clinic reception:

- is welcomed - EDD checked - Demographics are checked - Patient hands over hand-held notes - (prefilled by community midwife) - Patient given sticky labels

- Maternity Notes & Acute notes given to

midwife or clinician seeing patient.

Maternity Records Clerk and Clinic

Receptionist

Patient waits

(5 – 30 mins)

Patient called into exam

room:

- history taken (if not already done by community midwife or GP)

- BP – height & weight (if not done previously)

- Urine - Bloods - Explain wait for the

doctor - Any questions answered

Midwife

Consultant

Doctor

- Appointment slip to - reception - To scan and back to clinic - May need repeated scans - Pharmacy - Tertiary referral - Scan and amnio - Caesarean booking - Physio - Dietician - Diabetics - Social worker (and - appointment) - Discharge to - GP/MW if appropriate

Patient








Appendix 6 - Antenatal Clinics – Follow UP - PATIENT FLOW

Patient gets a follow up

appointment at the reception

or rings

PATIENT

Patient arrives at the clinic reception:

- is welcomed - Demographics checked - Patient hands over handheld notes - Sometimes patient would have had a scan prior

to clinic appointment

CLINIC RECEPTIONIST/MATERNITY RECORDS

Patient DNA’s

PATIENT

Patient waits

(5-30 minutes)

Patient called:

- week of pregnancy calculated - Bloods taken - BP, Urinalysis - Appropriate record keeping

MIDWIFE/CLINIC ASSISTANT

Patient waits

Consultant

DOCTOR

- further f/u appointment (with or without scan)

- Scan - CTG - Pelvimetry referral - Diabetic clinic referral - Admission date given - SI - LSCS date - Pharmacy - Discharged – GP/MW

care if appropriate

PATIENT








Appendix 7a - FIRE EMERGENCY PROCEDURE – ‘A’ FLOOR – PART 1

WOMEN’S SERVICES MATERNITY RECEPTION AND MATERNITY

RECORDS DEPARTMENT

ASSEMBLY POINT: OUTSIDE FRONT ENTRANCE TO MATERNITY BLOCK

1. Fire Alarm Point: Opposite main reception near public seating area

Outside security guards office.

Opposite main reception on wall between second entrance door and

window.

2. Extinguishers: On the wall by the public telephones.

Opposite main reception on the wall between the second

entrance door and windows.

3. Evacuation Routes: Fire exit in maternity administration office.

Main front door.

Rear staircase at back of clinic.

Corridor by maternity administration office.

WHAT TO DO IF YOU DISCOVER A FIRE

1. Operate fire alarm by breaking glass and dial 2222, giving location of fire. (DO NOT DIAL

999)

2. Where there is no risk – fight the fire with appropriate fire extinguishers.

3. Ensure all patients and visitors, including Tea Bar ladies, go to an area of safety.

4. All staff to go to allocated assembly point, where you should report to your manager.

ON HEARING FIRE ALARM IN MATERNITY

1. Escort all patients and visitors out of the building.

2. Ensure that Tea Bar ladies are aware that they should go to the assembly point.

3. All staff should go to allocated assembly point and report to your manager.

4. Always use the nearest fire exit, walking never running.

5. Remain at the assembly point until given further instructions.








Appendix 7b - FIRE EMERGENCY PROCEDURE – ‘X’ FLOOR – PART II

OBSTETRICS & GYNAECOLOGY CLINICAL SERVICE UNIT

MATERNITY RECEPTION AND MATERNITY RECORDS DEPARTMENT

ASSEMBLY POINT: OUTSIDE FRONT ENTRANCE TO MATERNITY BLOCK

1. Fire Alarm Point: Opposite main reception near public seating area.

2. Extinguishers: In corridor near room 8x48 (records library store) and room 8x39. In corridor outside room 8x34 (records library store)

Fire hose reel opposite lifts at bottom of stairs.

3. Evacuation Routes: Rear door by room 8 x 34 (records library store near kitchens). Past kitchen into link corridor and out of automatic sliding doors

by kitchens.

WHAT TO DO IF YOU DISCOVER A FIRE

1. Operate fire alarm by breaking glass and dial 2222, giving location of fire. (DO NOT DIAL 999)

2. Where there is no risk – fight the fire with appropriate fire extinguishers.

3. Leave building by quickest safe route, make way to allocated assembly point and report to your manager.

ON HEARING FIRE ALARM IN MATERNITY

Leave building by quickest safe route, make way to allocated assembly point and report to your

manager.

Documents

OPERATIONAL PROCEDURES MATERNITY & … protocols and guideline… · MAT-SOP-001 Operational Procedures Maternity & Gynae Admin, ... 1.1.3.3 Appointments Call Centre . Job Title Admin