FOI/2025/26/044

Request

I would like to request information regarding clinical documentation practices, specifically in relation to the capture of information during interventional procedures, such as Central Venous Access Device (CVAD) insertions.

1. Clinical Documentation

• What methods are currently used by clinicians to document key information during invasive procedures, such as CVAD insertions (e.g., paper forms, digital forms, voice dictation, other)?
  • Is any form of structured digital data entry used at the point of care for these procedures?
• Are standardised templates or proformas used Trust-wide for documenting invasive procedures, such as Local Safety Standards for Invasive Procedures (LocSSIPs)?
  • Are any of these LocSSIPs or other forms digitised?

2. Voice Technology

• Does the Trust currently use any voice-to-text or voice recognition technology for clinical documentation (e.g., Dragon Medical One, Nuance, Voice-Care, etc.)?
• If yes, which departments or specialties currently use it, and for which types of documentation?

3. Administrative Efficiency

• Has the Trust undertaken any assessments of the administrative time burden associated with completing procedural documentation (manual or digital)?
  • If so, is any information available on time spent per procedure or efforts to streamline the process

4. Future Plans

• Is the Trust currently planning any initiatives or procurements to digitise documentation processes for interventional procedures?
  • If yes, please outline the scope and timelines if available.

Response

1. Clinical Documentation

• What methods are currently used by clinicians to document key information during invasive procedures, such as CVAD insertions (e.g., paper forms, digital forms, voice dictation, other)? We do not provide invasive procedures such as CVAD
  • Is any form of structured digital data entry used at the point of care for these procedures?
  • N/A
• Are standardised templates or proformas used Trust-wide for documenting invasive procedures, such as Local Safety Standards for Invasive Procedures (LocSSIPs)? Not Applicable
  • Are any of these LocSSIPs or other forms digitised? Not Applicable

2. Voice Technology

• Does the Trust currently use any voice-to-text or voice recognition technology for clinical documentation (e.g., Dragon Medical One, Nuance, Voice-Care, etc.)? Dragon Medical One
• If yes, which departments or specialties currently use it, and for which types of documentation? Community Adult and children’s services (AHP and Nursing) .

3. Administrative Efficiency

• Has the Trust undertaken any assessments of the administrative time burden associated with completing procedural documentation (manual or digital)? No
  • If so, is any information available on time spent per procedure or efforts to streamline the process?  Not Applicable

4. Future Plans

• Is the Trust currently planning any initiatives or procurements to digitise documentation processes for interventional procedures? We are a community organisation and provide minimally invasive procedures, All clinical services document digitally on EPR, with some services using Mobile application capture and dictation direct to clinical EPR where appropriate.
  • If yes, please outline the scope and timelines if available.