The Electronic Casenote (eCn) by Murray Glaister

eCn, the new electronic casenote system, went live in the Mental Health Service on 1st December 2012.  This will be rolled out over the coming months and years to replace all the existing paper casenotes within secondary care across the region.

 The system has evolved several times in the five months since it went live. Feedback from users has helped to push the development in the areas that are needed most.

 The clinicians and support staff who now use the system on a day to day basis have provided all the development requests, reporting, suggestions, comments and criticism.  These are the people who help us most, they take the time to understand and work with us in eHealth to really start making it happen.

 My key message in this blog is to thank those involved so far for their time, understanding, criticism (where necessary) and support.

 So what is the casenote?

 Firstly, it is the place where all the information about patients is stored from treatment episodes and things that have happened to them over the course of interactions with any NHS services.  This information needs to be kept for future reference, to document what has happened and as a legal record of the treatment that has been provided to date, although much of it is probably never looked at again.

 We have started legacy scanning in several areas and our approach is to ‘scan as is’. The scanning team are NOT checking through the notes to make sure it is ordered and perfect before scanning commences. If records are in the wrong order in the existing paper casenote then the scanning team will replicate that wrong order in the legacy scan.

 We will also scan the volumes as they are.  If a patient has multiple volumes they will have multiple legacy scans. Similarly if they have visited several service areas they will have several legacy scans.  The exception to this will be the removal of some lab results which are routinely viewed via the Lab Web Browser and SCI store.

Secondly, but probably more importantly, the casenote is there to support clinical care. This involves easily accessing the relevant information.  The key to this is good and consistent document identification and classification. However, lessons learned from the earlier eMRec pilot and other national experience indicated that there was an even bigger danger in trying to classify documents in too much detail.

 Fortunately, there was a Scottish Group looking at producing national document classifications so we took their output and made Doc Type one of the four core components assigned to each piece of information (along with CHI number, date/time and Specialty).  It is not perfect and will evolve over time but it gives us something to start with.  Having the eCn filter results by Specialty, date/time or document group will allow a clinician to focus on individual documents as required or allow a wider, more holistic view, if necessary.

 Lastly, the broad use of casenotes is not about the storage of information, it is a document that is used as a prompt or a mechanism for a piece of work.

 The casenote appearing in an outpatient clinic means the clinician has to create a note, either directly by writing or via dictation.   The casenote on a desk is the prompt to review, write an inpatient summary discharge letter, return for dictation, filing etc.

 So this workflow or prompting needs to be thought through, understood and replaced in some way shape or form. There has already been some work carried out by health records looking at the Outpatient clinics in DGRI that we will soon be discussing with a wider audience.

 A final point of clarification, is that eCasenote will replace all paper casenotes , the legacy archive, the piles of notes found in the medical records store or in offices across the region as well as the stacks of paper that are transported daily around the organisation.

 In many instances, and for many people, the easiest way to record information is still to record it on paper. Outpatient Clinics may have blank pre indexed sheets to write on but these will be captured immediately after the clinic.

 Similarly, for inpatients in Midpark, notes are still collected during the stay, grouped together, separated and coded into main document category groups by the ward clerks before being sent for scanning.  Although we are starting to change that process.

 The first stage of the project is about gathering these paper records together as effectively as possible to help move towards going paperlite (reducing the dependence on paper, particularly in storage terms) which is different from paperless (removing paper altogether).

 Some consultants in Mental Health are now typing notes directly into eCn, with others testing and using laptops to access information off site.

 However, and this goes back to an earlier point, we are looking at changing systems that people have been working on and improving since 1948. In many ways the eCn will mean starting again, and it will be evolved and developed over time, with help from the front line staff, into the basis of a system we will use for the next 65 years.

 Murray Glaister is an eHealth Project Manager and would be happy to discuss the eCn with individuals or teams if they wish further information. He can be contacted via switchboard.

 Next week’s blog will be by Dr Ewan Bell Consultant Biochemist and Clinical Director for Diagnostics.




Most people working in healthcare are now familiar with the concept of patient safety – and its fundamental underlying principle that services can be considerably improved with better outcomes for patients simply by doing less harm.  No-one goes to work intending to harm people but strong evidence suggests that avoidable adverse events and mistakes have a huge impact on patients.  The acute programme in Scotland is nearing its goal of reducing mortality in acute hospital settings by doing this very thing ie avoiding harm where possible.  Lives are being saved.

 On the back of this patient safety programmes are now rolling out in mental health and primary care. 

 Is there anything unique to patient safety in mental health?


(These accounts are anonymised but based on real patient experiences)

John was first admitted to hospital when he was only 19 and had developed what sounded like a schizophrenic illness.  He had become withdrawn and increasingly paranoid.  He had been using drugs as is not uncommon and on admission to, in those days, the Crichton, he was very agitated, attempted to leave and so was ultimately transferred out of region to an intensive psychiatric care unit. 

 This was all part of a very terrifying experience – “I look back now and I remember feeling that everyone was against me and not really knowing what was going on.  When I got to the IPCU I immediately felt that I was being locked up and punished for something that I didn’t think I had done.  I got angrier and angrier and ended up fighting the nurses.  After a while, with the medication on board I felt a bit calmer but became aware of the other patients and that some of them were even more frightening than the nurses.  One of them suggested to me that the pills I was taking were doing more harm than good and I would be better taking some “blow” (cannabis).  I really didn’t want to do this because I was starting to realise that maybe I had been ill and maybe that things I believed had happened and the voices were all in my head.  I would have loved to have had the chance to speak to one of the nurses but I really didn’t trust them.  I remember going to the office where they all sat inside while we were wandering about – I knocked on the door and was told “2 minutes” – I went off and got the cannabis.”

 Clearly John’s account is coloured by the fact that he was suffering a paranoid illness at the time but he gives a very striking description of being afraid, not knowing who to speak to, and his attempts to be heard falling on deaf ears – “2 minutes”.  Does the way he was managed constitute less than ideal care?  Probably.  Does it constitute unsafe care?   The idea of sending him to the IPCU was to make him safer to protect himself from his behaviour and to protect others – but the way, in which it was done, the level of involvement that he had in the process may have left him feeling less and less safe. 


Alan is an accountant whose wife Jean developed a puerperal psychosis a number of years ago, again necessitating care in a psychiatric inpatient unit. 

Alan recollected “I remember going to the ward when Jean had been admitted.  Our baby son was too small to go into the hospital with her they told me and I looked after him with a bit of help from relatives.  He did eventually get to go to hospital and stay with his mum but only after a few weeks.  Those first few weeks were hellish – she was really quite disturbed, kept gathering things together, talking about daft stuff which was described as a manic state.  She certainly talked a lot, I remember visiting her and she was looking in a hell of a state which was unlike her, she was normally very well presented (she is a professional person herself) and there she was in a baggy dressing gown which was gaping open revealing huge damp patches on her nightie where she was leaking breast milk. 

What really bothered me was that she had struck up a friendship with one of the blokes on the ward and I am quite certain that he thought he had a chance of becoming her “boyfriend” giving the disinhibited way she was acting.    I remember speaking to the nurses who said that they were aware of this and they would keep an eye on it.  I didn’t think she was safe.”


The two patient stories above illustrate different aspects of possible harm and the Scottish Patient Safety Programme in Mental Health (SPSP-MH) is set up to try and address these and the other forms of harm which perhaps people more immediately think of.  As with adverse events in general for acute hospital settings, medication error and falls account for the bulk of all adverse events. However failing to protect vulnerable patients, either from their own actions (self harm, disinhibited behaviour etc) or from the exploitation of others are also adverse events and causes of harm which the programme tries to address, as is the risk of violence to others.


The SPSP-MH is a four year programme and  by the end of the 4 years it is hoped that harm in mental health settings will be significantly reduced.  The baseline measurement of where harm occurs is being carried out at the moment and an overall target will be developed as the programme further develops.

There are a number of work-streams including work around risk management, communication at transition points, seclusion and restraint, and medicines management. There is also an overarching area of work looking at culture and leadership, with a genuine emphasis on service user involvement running through the programme.

  A very important aspect of measuring the success of a programme to make mental health services safer, has been around the development of a patient safety climate tool for service users. The local team in Dumfries, based in Balcary ward, have been heavily involved in helping develop this which was initially created by service users themselves linked to the organisation VOX (voices of experience). Even during the pilot phase of developing this tool- useful insights into what makes patients feel safe or unsafe have been highlighted.


The description of the early experience of using the patient safety climate tool for service users takes us back to why it’s important to hear stories such as John and Alan & Jean’s.  Ultimately the patient safety programme in mental health will measure its success by a reduction in adverse events and by mapping changes in the ‘basket of measures’ which has been developed.  However, if wards or services exist where patients, or staff, describe feeling unsafe and insecure then the programme will have failed, in my opinion. I would also suggest that patients in general hospitals may not always feel safe or that they know who to speak to or that they are being heard. The phrase “2 minutes” might sometimes be used by staff to patients in general hospital wards? It may be that the Patient Safety Climate Tool for patients is something which could be applied across all health facilities?

 I will give the last word to John.  “I have now been in and out of hospital for the last 7 or 8 years but I have to say that in the last year I actually asked to go in a couple of times because I knew I was struggling.  It’s a nice new ward but the thing that I noticed most was that the staff really seem to have a bit more time to listen to you and I felt that I could go and ask them for help when I needed it.  There were some folk who I was still a bit wary of, but I also found space and time for myself so I didn’t feel intimidated and I felt a lot happier hence asked to go in.  I think you can just sense sometimes when a place is going to help you rather than make you feel worse.”

Dr David Hall is a Consultant Psychiatrist, Clinical Director Mental Health NHS D&G and National Clinical Lead SPSP-MH

Next weeks blog will be by Murray Glaister from the IT Dept

If you are enjoying reading the blog you may wish to take a look at this blog from Building Healthy Communities in the Machars ,

Pride, Passion, Professionalism by @HazelNMAHPDir

I was racking my brains for a topic to post on the Blog this week – seemed like a long way off when I confidently said ‘yes’ to Ken.  Then it struck me that I should write about something that I felt passionate about……….. nursing and hope that my meanderings would fit the bill.

I am one of those people who never wanted to do anything else but become a nurse. I have no idea where the notion came from, but know that from a very early age, when relatives would ask “and what do you want to do when you grow up?” my answer was always nursing.

In fact I spent a day shadowing a community mental health nurse (thanks Judy) last week out in Stranraer and she asked me what would I have done if I had not been a nurse?  I could not think of an answer as the thought had never occurred to me before! I am still not sure what my answer is.

It came as a bit of a shock to me earlier this year when I realised that in 2014 I will have been in nursing for 30 years. I have no idea how that happened and it has passed by in a flash, but it made me think about the strong characters who have probably helped shape me over the years.

One of my first memories is my very first student placement in a Care of the Elderly Rehabilitation Ward. All the patients who were able were helped up to the dining room for breakfast and while they were enjoying this, the Ward Sister would make up a bucket of bleach, strip all the beds and wipe them all down. That left me with a lasting legacy that both Martin Connor and Elaine Ross will attest to!Hazel pic

Progression through my training was marked by changing the number of stripes on my hat – each additional stripe adding a little pressure as it identified me as someone with a little more knowledge. As a first year student the sense of awe we felt when working alongside a third year student should not be underestimated, but my how I hated that hat.

The sense of bursting pride when I got to ‘put my stripe up’, was presented with my hospital badge and got my first staff nurse post was incredible. The Ward Sister I worked for then still sits on my shoulder to this day. Her sense of compassion, strength of feeling about what was acceptable and what our patients should expect from us was very powerful. She knew every patient and their family with what seemed to me, as a newly registered nurse, a supernatural ability and I desperately aspired to be like her.  When I finally became a Senior Charge Nurse years later – she was the role model in my head.

I am proud to be the Nurse Director here in Dumfries and Galloway and feel like I have the energy for another 30 years. However the most satisfying and hardest role I have been in was that of a Senior Charge Nurse, with the need to be all things to all people. I can honestly say that I loved my job at that point in my career. Indeed – there are consultants here who worked with me in that role – and if you can guess who they are – you could ask them whether my aspiration held true.

What keeps my feet on the ground and re-affirms my values are undertaking clinical and shadowing shifts with nurses at the point of care – so keep your eyes peeled I could be working alongside you very soon……….

Hazel Borland is Executive Nurse Director for NHS Dumfries and Galloway

Next week Dr David Hall, Consultant Psychiatrist, will post his first blog for dghealth.





Front Page News by @andyecc71

Towards the end of 2012 I was invited to take up the post of Scottish Workforce Officer for the Royal College of Paediatrics and Child Health. It seemed an excellent opportunity – workforce issues have been a major problem in paediatric departments across Scotland, particularly so in Dumfries. I was assured that my responsibilities would be straight forward with a few committees to attend and two reports to write each year.

Within 2 weeks of taking up the post however, things became less straight forward. The media had taken an interest in paediatric staffing problems within Lothian and the College were approached by The Herald for an interview. Somebody thought the new Workforce Officer would be the ideal interviewee. My first response was panic. I had no media experience and was very new to the College role but this was a major opportunity. In particular, I had the chance to highlight a major problem affecting paediatrics across Scotland. I needed to make the most of this so I set about getting prepared.

Firstly I clarified what was expected of me from the College since I would be representing them. Thankfully they have lots of media experience and had a variety of position statements and national data available for me to study over the next few days. I also spoke directly with the Chair of the Scottish Committee, ensuring I understood the views of the College within Scotland. Knowing key facts and figures as well as understanding the College position would be critical.

I also presumed (correctly) that any journalist would be interested in my views on the workforce situation from our local perspective. Whilst I was happy to represent the College I was anxious to ensure that my employer had no reservations about me being interviewed. A discussion with the Medical Director reassured me that he was comfortable with the proposed interview.

The interview itself was much easier than I expected. I had done my homework, knew my facts and was able to stick to the relevant subjects. I realised early during the interview that it was important to distinguish between facts and opinions. More importantly, I realised the importance of clarifying which statements could be used as direct quotes – I wanted to be particularly sure I didn’t say anything that could be misunderstood.

The worst part of the whole experience was waiting for publication. Before running the story the newspaper wanted the results of a freedom of information request, giving exact data on the national staffing situation. This would take a fortnight and I spent that time worrying how my comments would be reported.

The day before publication I received a phone call from the picture editor who urgently needed a photo of me for the article. This, I hadn’t prepared for, but smart phones these days are incredible and I emailed in a hastily taken photo (my daughter is very proud that she’s now a published photographer!)


In fact, the article was very balanced and my comments were accurately reported. The journalist had researched the story well and included an excellent analysis of the situation taken from my comments and those of several other clinicians. I did wonder if the story would be picked up by other media and indeed it was – I was subsequently interviewed by the Times and the local newspapers. The political follow up was interesting with the issue being debated in Scottish Parliamentary questions.

Our staffing crisis hasn’t got any better yet but at least people are now talking about the issue.

The front page article can be found here:

Dr Andrew Eccleston is a Consultant Paediatrician at Dumfries & Galloway Royal Infirmary

Next week Hazel Borland @HazelNMAHPDir will discuss ‘Leadership & Challenges for the future”