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Information for Staff
Guideline Submission Form
Guideline Submission Form
Clinical Guidelines Submission Page
Step
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9
11%
What type of document have you created?
*
Policy
Clinical Guideline, Protocol or Procedure
Patient Information Leaflet or Proforma
Clinical Algorithm
To review the definitions of each document type click
here
Please note that in addition to submitting your document through this system all policies also require presentation to the Policy Scrutiny Committee, please contact
Clinical.Guidelines@southerntrust.hscni.net
Please note that clnical algorithms should ldeally form part of the overall clinical guidance document.
If you wish to have your document conisdered as a standalone item please complete the rest of the information as required then upload your document.
Patient Information Leaflets that relate to clinical guidelines can be considered for adding to the onine catalogue. Ideally these should be incorporated into the guideline that they are relevant to however if you feel that the leaflet should be provided as a standalone document you can submit via this
form
Please complete the below form with all the relevant information. At the end of the form you will have the opportunity to upload your document.
Author Details
Title
*
Name
*
First
Last
Designation
*
Speciality
*
Directorate
*
Acute
Older People and Primary Care
Children and Young Peoples Services
Mental Health and Learning Disability
Medical Directorate
Clinical Division
*
ATICS
Surgery & Elective Care
Medicine and Unscheduled Care
Cancer and Clinical Services
Integrated Maternity & Womens Health
Emergency Medicine
Infection Control
Phone Number
*
Email Address
*
Document Information
Is this a New Guideline, Revision to and Existing Guideline or Replacement Guideline?
*
New Document
Revision to an existing Guideline
Replacement Guideline
Name of Guideline / ID of existing guideline
*
Name of Guideline / ID being replaced
*
For replacement & updated guidelines you will still need to complete the submission form.
This is is to provide assurance that your guideline will not wider impact based on any changes. If you have previously obtained relevant committee and no major changes occur please use the original dates of approval. If you cannot recall these please contact the clinical guidelines team who will have records of guidelines that are listed on the website.
Please note that the Clinical Guidelines Management Team are only responsible for manging guidelines that are hosted on this website.
If old versions exist elsewhere such as the Trust intranet it is your resposibility as lead author to wnsure these are removed. Please contact the Trust Communications team.
Does this link with any other guideline/s?
*
Yes
No
Name / ID of linked Guideline/s
*
Have this Clinical Guideline been consulted on?
*
Yes
No
Please give details
*
Guidelines that Involve Medicines
All guidelines that involve medicines require approval by the Drugs and Therapeutics Committee.
Guidelines that involve Medicines are defined as follows:
1.The clinical guideline has clinical implications for multiple directorates or is expected to have implications for Primary Care in terms of cost or practice.
2. There are significant new cost implications (>£1,000 p.a.)
3. There are significant new service implications
4. The clinical guideline has been produced by a Managed Clinical Network
5. The clinical guideline includes medicines not previously approved for use in the Trust or medicines not on the HSCB Regional Formulary.
6. The guideline involves the use of an unlicensed medicine or the use of a medicine outside its license.
Having considered the above criteria does this guideline involve medicines?
*
Yes
No
Have you obtained approval from the Trust Drugs and Theraputics Committee?
*
Yes
No
Please complete the Clinical Guideline ID tag and forward to tracey.boyce@southerntrust.hscni.net. If approval is granted by the Drugs and Theraputics Committee please return and submit the guideline.
Date of D&T Meeting
*
MM slash DD slash YYYY
Approved By (Chair of Meeting)
*
Implications and Costs Associated with Clinical Guideline
Please complete the below questions.
The clinical guideline has significant clinical implications for multiple directorates and / or is expected to have significant implications for Primary Care
*
Yes
No
There are significant new cost implications
*
Yes
No
There are significant new service implications
*
Yes
No
Adoption of and External Clinical Guideline e.g. NICE
*
Yes
No
Your clinical guideline requires SMT approval, please enter details of approval below. If you have not yet sought SMT approval as lead author you are required to ask the operational lead director to present this for approval. When SMT approval is granted you can provide the details in the box below.
Have you gained Senior Management Team Approval?
*
Yes
No
Date of Senior Management Team meeting
*
MM slash DD slash YYYY
Approved By (Chair of SMT Meeting)
*
Clinical Guidelines that Relate to Exclusively to a Professional or Functional Group
Does the Clinical Guideline have implications relating to a specific clinical group (Functional or Professional) and has this been assessed to ensure that it does not have wider implications?
*
Yes
No
Have you obtained approval for the guideline from the relevant divisional governance / professional forum?
*
Yes
No
Name of divisional governance / professional meeting
*
Approved By (Chair of Meeting)
*
Date of relevant Governance / professional meeting
*
MM slash DD slash YYYY
Additional Information (e.g. additional approvals)
Please complete submit your guideline to the relevant divisional governance meeting or professional group for approval.
Clinical Guidelines that Relate to Exclusively to an Individual Department / Clinical Area or Directorate
Does the Clinical Guideline have implications relating to an individual department / clinical area? This includes guidelines that are solely authored by a single specialty / directorate but may be used in other areas
*
Yes
No
Have you obtained approval for the guideline from the relevant divisional governance / department forum?
*
Yes
No
Name of divisional governance / department meeting
*
Approved By (Chair of Meeting)
*
Date of relevant Governance / Departmental meeting
*
MM slash DD slash YYYY
Additional Information (e.g. additional approvals)
Please complete submit your guideline to the relevant divisional governance meeting or department meeting for approval.
You have indicated that you have not consulted on the content of your guideline. As you guideline has not been approved by any Trust Committee or Forum you are required to consult on the content. If you have consulted please click the previous button to return to page two and give details.
Presentation of Guideline
Which division would you like to have your Guideline listed under (This is only for search purposes and does not restrict access to staff)
*
Acute Paediatric
Anaesthetics & ICU
Antibiotic Prescribing
Cancer & Clinical Services
Child And Adolescent Mental Health Service
Community Paediatrics
Elective Care
Emergency Medicine
Infection Prevention and Control
Integrated Maternity
Medicine & Unscheduled Care
Mental Health and Learning Disability
Which speciality would you like to have your Guideline listed under (This is only for search purposes and does not restrict access to staff)
Have you completed the Clinical Guideline ID tag as required below and added to the front page of your document?
*
Yes
No
You are required to complete the Clinical Guideline ID tag and add this to the front of your document, a copy of the template can be found
here
Name of Clinical Guideline As you would like it listed
*
Take time to consider how your document will be titled, this will be used by the website search function to locate Guidelines.
Date next review due
*
MM slash DD slash YYYY
Guideline Keywords
*
Please enter up to 10 relevant keywords seperated by commas to help staff locate your guideline. (e.g. anticoagulation, warfarin etc)
Upload Your Guideline
*
Accepted file types: doc, docx, ppt, pptx, pdf, pub, pubx, docm, Max. file size: 20 MB.
Please note that guidelines should ideally be provided in editable formats for future-proofing revisions. If you have any questions please email clinical.guidelines@southerntrust.hscni.net
Also in this Section
Also in this Section
Guideline Submission Form
