Documentation

About the enquirer:

  • Full name of enquirer spelt correctly or correct generic code for enquirer selected (if appropriate)
  • Correct organisation linked to enquirer or correct generic organisation code used (if appropriate)
  • ‘Contact for this enquiry’ section completed and indicates the enquirer’s full name, position, contact details (ideally telephone AND email) if generic enquirer codes used. All addresses must contain a town and postcode.
  • An email address is provided if possible (for the purpose of possible future user survey).
  • None of this information should appear in the ‘question’ or ‘answer’ fields in the enquiry. Use designated fields, comments box or notes box as appropriate.

About the question:

  • There must be a clear, unambiguous question that can be understood by a third party.
  • Sufficient background information is provided in order to answer the question and/or aid understanding of the issue(s).
  • Abbreviations are avoided where possible and any abbreviations present in the original enquiry are expanded.
  • Comments box used to communicate any relevant information to colleagues, e.g. ‘due by 13.00’ (even if the time has been amended to reflect this).

About the patient (if relevant):

  • Identifier (if needed) – e.g. name, initials, hospital number, ward
  • Date of birth or age
  • Weight (if paediatric or if needed for calculations)
  • Height (if needed for calculations)
  • Blood results (if relevant to enquiry)
  • Past Medical History and Drug History (including pregnancy/breastfeeding status, if relevant to enquiry)
  • Do not put patient identifiable data (PID) in the question and answer fields. Please refer to Recording Confidential Data on MiDatabank.

About a ‘general’ enquiry (i.e. no patient involved)

  • ‘Patient centred enquiry’ category un-checked

About the resources:

  • Names of all resources used are stated clearly with the following additions:
    • Books/Journals: edition number/ date & page numbers.
    • Databases: dates searched/accessed/ search terms used/ date of last revision or update where available.
    • People: full name (where possible) and job title of people spoken to where possible e.g. company Medical Information Departments/ specialist doctors/ pharmacists / hospital plus contact number or email address.
    • Other electronic resources e.g. websites: name and/or full address of website(s) used/ date accessed/ search terms used.
  • Where no relevant information found, this should be stated.
  • Relevant information for each resource is presented in a concise manner.

About the answer:

  • A statement of the answer to be given (i.e. final version) is present in the answer field. All other versions of the answer (if present) should be moved into research and coded under ’drafted answers' or similar.
  • Do not enter any PID or enquirer identifiable data (EID) into the ‘question’ and ‘answer’ fields. Please refer to Recording confidential data on MiDatabank.

Overall:

  • The audit trail should be clearly seen through use of ‘control M’ (name, time and date stamp) (plus name of member of staff if a generic MiDatabank login is used) for all steps such as, resource added, contacting others, answer written, answer checked, answer given, etc.
  • All fields must be checked for typographical and grammatical errors.
  • All calculations must be documented and checked using the ‘control M’ function.
  • Where drafts of answers are kept, ensure that nothing has been deleted or overwritten following checks made (for audit trail or training purposes), e.g. checker comments, corrections, re-writes of answer. Drafts must be kept in the ‘Research’ section of MiDatabank. Only the final answer should be present in the ‘Answer’ field to prevent a draft answer being given out in error.

Analysis

  • Sufficient background details have been taken as per the UKMi enquiry answering guidelines to allow a third party to correctly answer the question in the time given if necessary.
  • Responses are documented for the relevant issues, e.g. ‘drug allergies – NKDA’.
  • The staff member taking the enquiry in has understood the question being asked and has considered potential follow-up questions, e.g. drugs in pregnancy should also consider safety in breastfeeding where appropriate, choice of antimalarial for travel should also cover vaccination requirements.

Coverage

  • Resources have been selected as per UKMi enquiry answering guidelines and/or local standard search patterns, and are relevant for the question asked.
  • Information from resources has been added appropriately. Where no information was found, this is documented appropriately.
  • Additional resources used must be of appropriate quality and trustworthy origin.
  • Where resources have not been used in a logical fashion, a discussion with the trainee should be considered for the purposes of training/reminding.
  • Correct utilisation of resources. The extent of confirming this will be at the discretion of the checker.

Answer

  • The answer documented addresses the question(s) asked and any surrounding issues, and does not include irrelevant information.
  • The answer includes all relevant information and advice appropriate to the situation, even if this was not directly asked for.
  • The answer is clear, concise, constructed in a logical fashion, is supported by the evidence found and may include opinion. In the case of the latter, this must be made clear in the answer.
  • The answer is safe and gives practical advice.
  • The appropriate route is used to convey the answer, e.g. written response or verbal followed up by written response for high-risk/complicated enquiries.
  • For written responses consider the use of subheadings and proof-read the answer for typographical errors and grammatical errors in Word.
  • Referencing, bibliography and attachments to written responses are used appropriately.
  • No PID or EID is in the ‘question’ or ‘answer’ fields. Please refer to Recording confidential data on MiDatabank.
  • If there are no patient/enquirer details present except in the correct places (enquirer details box and patient details box) the ’patient and enquirer anonymity’ box has been ticked before completing the enquiry. This must be done if the enquiry is to be shared nationally.

Last Reviewed: Oct 2020