Patient Master Index (PMI)

Transcription

1 Patient Master Index (PMI) PMI Add and Revise Version 4.23 February 2012 ICT Training First Floor, Victoria House Queen Alexandra Hospital Cosham PO6 3LY Tel: ext: Website: ICT TRAINING has made every effort to ensure that the material in this manual was correct at the time of publication but cannot be held responsible for any errors or inaccuracies. ICT TRAINING reserves the right to change or replace information contained in the manual without notice. For the most up to date version please refer to the ICT Training website. All references made to patient records are fictitious for the purpose of training only. PMI Add and Revise VN4.23

2 CONTENTS 1. GENERAL COURSE INFORMATION INFORMATION GOVERNANCE What can you do to make Information Governance a success? CONFIRMATION OF DETAILS PROCEDURES INTRODUCTION ADD NEW PATIENT DETAILS <PMI> Patient Basic Details Screen Record Other Details Registration Details (Screen 2) Casenotes (Screen 3) REVISE DETAILS OF AN EXISTING PATIENT <PMI> No. 1 Revise Basic Details No. 2 Registration Details No. 3 Casenotes No. 4 Episodes MAINTAIN FUNCTIONS Maintain Address History <MAH> Maintain GP History <MGH> Maintain Surname History <MSH> CASENOTE NUMBER LOCATION EXPLANATION LIST EPISODE STATUS DESCRIPTION SPECIALITY CODE LIST PAS MASTERFILES REQUEST FOR POSTCODE PAS MASTERFILES - REQUEST FOR GENERAL PRACTITIONER (GP)/ SURGERY PAS MASTERFILES REQUEST FOR DENTIST AUTO POSTCODING HELP SHEETS Ways of Searching Other Tips FAULT REPORTING ICT Service Desk Out of office hours...28 PMI Add and Revise VN4.23

3 15.3. ICT Training HELP WITH USING PAS ICT TRAINING CANDIDATE APPEALS PROCEDURE VERSION CONTROL/LOG...31 PMI Add and Revise VN4.23

4 Patient Administration System (P.A.S) Course 1. GENERAL COURSE INFORMATION COURSE TITLE METHOD OF TRAINING DURATION PMI ADD & REVISE Workshop Recommended 2 Hours PRE-REQUISITES PMI Basic Level 0 ABOUT THE COURSE This course will show students how to enter a new patient onto the PAS system with full and accurate details, and how to update records for existing patients with new information. Students will also be shown how to view historical demographic information for a patient. SUITABLE FOR All staff Clerical and Clinical OBJECTIVES This course will enable the student to: 1. Identify when a patient is NOT on the PAS system and needs to be added. 2. Add a new patient to the PAS system with all the patients demographic details and Casenote number. 3. Revise existing patient s details. 4. Follow the correct rules and guidelines whenever adding or editing any patient information. 5. View address, GP and GDP history for a patient. 6. Identify specific information, e.g. GP, Casenote Number, etc. 7. Use the Auto-Post coding system to find addresses using several different methods. 8. Deal with special case scenarios, e.g. No Fixed Abode and Military patients. PMI Add and Revise VN4.23 1

5 2. INFORMATION GOVERNANCE Information Governance (IG) sits alongside the other governance initiatives of clinical, research and corporate governance. Information Governance is to do with the way the NHS handles information about patients/clients and employees, in particular, personal and sensitive information. It provides a framework to bring together all of the requirements, standards and best practice that apply to the handling of personal information. Information Governance includes the following standards and requirements: Information Quality Assurance NHS Codes of Conduct: o Confidentiality o Records Management o Information Security The Data Protection Act (1998) The Freedom of Information Act (2000) Caldicott Report (1997) Further information can be accessed through the Trust Intranet: Information Governance (Departments sections), and Management Policies (Policies section) 2.1. What can you do to make Information Governance a success? Keep personal information secure Ensure confidential information is not unlawfully or inappropriately accessed. Comply with the Trust ICT Security Policy, Confidentiality Code of Conduct and other IG policies. There are basic best practices, such as: Do not share your password with others Ensure you "log out" once you have finished using the computer Do not leave manual records unattended Lock rooms and cupboards where personal information is stored Ensure information is exchanged in a secure way (e.g. encrypted s, secure postal or fax methods) Keep personal information confidential Only disclose personal information to those who legitimately need to know to carry out their role. Do not discuss personal information about your patients/clients/staff in corridors, lifts or the canteen or other public or non-private areas Ensure that the information you use is obtained fairly Inform patients/clients of the reason their information is being collected. Organisational compliance with the Data Protection Act depends on employees acting in accordance with the law. The Act states information is obtained lawfully and fairly if individuals are informed of the reason their information is required, what will generally be done with that information and who the information is likely to be shared with Make sure the information you use is accurate Check personal information with the patient. Information quality is an important part of IG. There is little point putting procedures in place to protect personal information if the information is inaccurate. PMI Add and Revise VN4.23 2

6 Only use information for the purpose for which it was given Use the information in an ethical way. Personal information which was given for one purpose e.g. hospital treatment, should not be used for a totally separate purpose e.g. research, unless the patient consents to the new purpose Share personal information appropriately and lawfully Obtain patient consent before sharing their information with others e.g. referral to another agency such as, social services Comply with the law The Trust has policies and procedures in place which comply with the law and do not breach patient/client rights. If you comply with these policies and procedures you are unlikely to break the law. For further Information Governance training refer to: Written by PHT Information Governance Manager, Sept 2010 PMI Add and Revise VN4.23 3

7 3. CONFIRMATION OF DETAILS PROCEDURES To ensure that the Patient Administration System (PAS) contains up to date particulars of all patients being treated, staff must verify with patients their personal details. This should be undertaken when the patient is arriving at the hospital on admission or when attending for an outpatient clinic or other types of appointment. The types of details we must verify are those within the Patient Master Index (PMI) function within PAS and covers the following items: Patient Forename, Surname and Title Date of Birth NHS Number (If not one shown on screen) Address and Postcode Telephone Number Home and Work numbers Name and Practice Address of GP Religion Marital Status Next of Kin Ethnic Group Military No (If applicable) By checking the above details with the patient, we are ensuring the following: * PAS contains the latest details for all our patients. * Mistakes or old details can be amended. * Information relating to the patient s well-being, such as Religion and Ethnic Group, can be used in patient care. * Emergency contact details for relatives are up to date. In some circumstances it will be difficult to verify the details highlighted above as the patient may not be coherent at time of arrival (eg emergency admission, A&E, etc). However, it is important that at the earliest opportunity, the details are verified and amended accordingly. Important If details are amended*, please remember to print a new set of labels, remove and destroy any incorrect labels from casenotes. We must not retain any labels that do not contain current details. Many thanks for your cooperation. Prepared by: ICT Information Manager Issued: January 2003 Reviewed: July 2011 Version No: V1.2 * To amend patient details you will need to have access to PMI at level 1. Please book the course PMI Add and Revise. In the meantime make sure you ask a colleague with access to amend the patient record PMI Add and Revise VN4.23 4

8 4. INTRODUCTION The functions of PMI access level 1 enables you to ADD a patient to the Patient Master Index or REVISE details of an existing patient. This process should be undertaken after searching for the patient using the LIS function. NOTE: ALWAYS SEARCH IN <LIS> AS IT IS THE ONLY FUNCTION WHICH GIVES A FULL SEARCH OF THE PMI. THOROUGH AND ACCURATE SEARCHES MUST BE MADE, FOLLOWING PMI LIS PROCEDURES. Recommended Procedure: Surname, Forename Initial, Date of Birth and Sex. Subsequent Methods to Try: Remove forename initial Remove the DOB Remove the sex Convert the DOB into an age Adjust the years +/- box (0-9) Remember only use the initial of the forename Use less letters (shorten) the surname Use the swap forename and surname option Use the similar sounding names option The results of these searches will be: No matching details found, in which case see ADD instructions (page 6). Matching patient found. If some amendments needed see REVISE instructions (page 13). PMI Add and Revise VN4.23 5

9 5. ADD NEW PATIENT DETAILS <PMI> The following procedure should only be used if you have tried all of the different searching techniques to ensure the patient does not already exist on the PMI Patient Basic Details Screen Select function PMI (Add/Revise) and enter patient details again using Surname, Forename, Date of Birth and Sex. At try again prompt, enter NO, press <Enter>. By entering NO you are indicating to the system that you don't want to search again, but wish to enter new information. PAS NUMBER Enter patient s date of birth into PAS Number box without any formatting (i.e.: no dashes, commas etc), and enter 6 digits only. E.g.: A date of birth of 23/05/1956 should be entered as The system will allocate the last 2 digits automatically, it is important you allow the system to do this, DO NOT enter 8 digits in the first place. NOTE: If Date of Birth is unobtainable, e.g. Patient unconscious, Enter Z and press <Enter>. The System will allocate a 'dummy' number. NHS NUMBER (if known) This is an important field so every effort must be undertaken to obtain the patient s NHS number. This and the patient s demographic details can be found using the Summary Care Record system (SCR). MILITARY NUMBER (if applicable) If applicable enter the military number for the patient. SURNAME Patient s surname only. FORENAMES Patient s first name. DOB Patient s Date of Birth. You will notice that the computer will calculate the patient s age automatically once you press <Enter>. AGE Only enter something in this box if you do not have a Date of Birth for the patient. SEX Choose from the 4 available options: F Female I Indeterminate (Sex of patient cannot be determined, i.e.: Premature baby) M Male U Unrecorded (Sex of patient Unknown) PMI Add and Revise VN4.23 6

10 PREFERRED NAME Enter the name the patient prefers to be known by if different to the forename. TITLE E.g. Mr, Mrs, Miss, Ms. Press Super-Help for a complete list of all available options. The list includes Military titles. WORK PHONE This box should be used to record work number if appropriate. HOME PHONE This box should be used to record the personal mobile number of the patient or a home land-line telephone number if preferred. Where possible the Trust aims to record the mobile number to enable text message appointment reminders to be sent to the patient. There is space for both home and mobile numbers to be recorded by removing the usual spacing within each number. ADDRESS (POP-UP WINDOW) The screen will display boxes for Extended Address and PMI Address. This now allows you to access the auto postcode search. The reasons for the 2 address boxes are: The Extended Address (top box) will be used to appear on patient letters. You will be able to view this full address in Add & Revise. The PMI Address (bottom box) will appear on the basic details screen as normal. This address will print on labels. 1. On the Extended line press F9 (Super- Help). This will now enable you to perform various search techniques to find the address you need, some of your search options are using: HOUSE NUMBER, POSTCODE: Will return one house only if found. POSTCODE ONLY: Will return a list of all buildings covered by that postcode, select the building required from the list, and press <Enter>. STREET NAME, TOWN: Will return a list of all buildings down the specified street in that town. Select building from list and press <Enter>. HOUSE NAME, TOWN: Will return all buildings with the specified name within the town specified. Select building from list and press <Enter>. HOUSE NUMBER, STREET NAME: Will return a list of locations anywhere in the country where the system has found a matching house number and street name. Select a location and you will then be presented with the available matches within that location. WHOLE ADDRESS WITHOUT POSTCODE: If you enter a valid address in the correct format, the system will return the postcode for that address, if it is correct, just press <Enter>. PMI Add and Revise VN4.23 7

11 At any point when searching for addresses, when you have a list on the screen, 2 options will always be available at the bottom of the list: Previous Level of Address: Change Selection Criteria: Will take you back one screen. Will allow you to change your original address search. 2. When the correct address is displayed select it with the highlight bar and <Enter>. This will add it to the Extended Address box. 3. <Enter> though the address boxes until the Basic Details screen is displayed. As you do so the new address and postcode will update in the PMI Address box. 4. If the required address cannot be found, having tried several different search combinations, delete all address details in the Extended Address box by pressing the F2 key. <Enter> to the PMI Address Box and type in the address (including the postcode). If the system accepts the address but not the postcode, leave the postcode field blank, and complete a 'Missing Postcode Form' (sample on page 21). NOTE: The address will not automatically appear until you have completed the Enter?' <Y> yes prompt on the PMI Basic Screen. You can use the F7 key to refresh the screen to display the new address. NOTE: Military Patient addresses on the front screen must always be their base address for security reasons. For more information about auto-postcoding, including how to deal with foreign addresses and no fixed abode, please see page 24 of this manual. MAINTAIN POSTAL ADDRESS This box is used to provide a postal address for the patient s correspondence that is an alternative to their permanent place of residence. It is NOT used for entering in a previous address for the patient. The default answer for this box is set to NO. Please leave this at NO unless you have been given instructions on the use, rules and authorisation for this field. In the case of Military Personnel you must enter the following address without stating an end date: MDHU Portsmouth Albert House Queen Alexandra Hospital Cosham PO6 3LY PMI Add and Revise VN4.23 8

12 All letters for Military patients will go direct to MDHU (MPAC) and it will be their responsibility to ensure the patient is informed and attends the planned appointment/admission. COMMENTS The purpose of this field is for use for the following information only: Box No for deceased patient notes Box No for moulds for MFU patients Twins... and in some cases doubles Under certain circumstances other comments are entered into this field, but they are to be agreed by the ECR Development Service Manager. ENTER To save the patient s record on the system enter a Y in this box and press <Enter>. If you do not wish to save the record enter N The word *Full*, now appears on the left hand side of the address, indicating that the extended address box is complete. This is the front BASIC SCREEN of the patients registration. You must continue on to record other details Record Other Details Select appropriate number from the taskbar at the bottom of the PMI Basic Details screen to register other details. No 1 Revise Basic Details: Allows you to revise information in the Basic Details screen. No 2 Reg Details: Enter GDP (Dentist), GP (Doctor), NOK (Next of Kin), Religion, Marital Status, Occupation, etc. No 3 Casenotes: Enter Casenote Number(s), etc. No 4 Episodes: Display any episodic details Registration Details (Screen 2) The questions on this screen ask Do you wish to view? Answer YES or NO as required. GDP and GP Having selected <Yes> use F9 (Superhelp) at the code prompt to locate the patient s registered GP or surgery and Dentist codes. SEARCH ON Enter Surname or part Surname to search, or in the case where a patient is registered to a Surgery enter surgery name or part name. Screen will show selection list, select by using Arrow Key until correct GDP/GP/Surgery is highlighted, press <Enter>. PMI Add and Revise VN4.23 9

13 Code prompt Search on Check this is the correct GDP/GP/Surgery required, press <Enter>. NOTES: - Entry of the registered GP details is vital to mandatory - Remember to try different searches try just the first letter(s) of GP s surname, the full spelling could be different, e.g. Taylor and Tailor. - Increasingly patients will be registered with a Surgery rather than an individual GP. Be aware that you can search for surgery name in the Search On field. - For a MEDICAL OFFICER for SERVICE PERSONNEL search using the military base name e.g.: HMS NELSON search using NELSON. GP NOT KNOWN/NOT REGISTERED Recording the patient s registered GP/Surgery is mandatory. However, there may be times when you are unable to add a GP s name or the Surgery to a patient s details, for example: 1. If the Patient GP/Surgery is not known to the System or the Patient. 2. If the patient chooses not to give you their GP s name. 3. If the patient is not registered with a GP/Surgery. If this happens either search on NOT or enter one of the following codes: NOT KNOWN GP/SURGERY NOT GIVEN NOT REGISTERED GP/SURGERY Remember to also complete a Missing GP form and send to the relevant department (see sample copy page 25). PMI Add and Revise VN

14 NOK (NEXT OF KIN) Enter Y (Yes) to view NOK. Type in full name (free text) and relationship or press F9 (Superhelp) to select correct relationship. If relationship is husband/wife, or mother/child under 16, the address is automatically entered although the cursor stays on the first line to allow for changes if required. COMMENTS Enter information as required, e.g. Ring after 6.00pm, etc. NOTE: This information may only be viewed on this screen. OTHER DETAILS Religion } F9 (Superhelp) (Mandatory) Marital Status } F9 (Superhelp) (Mandatory) Place of Birth } Free Text Ethnic Group } F9 (Superhelp) (Mandatory) Occupation } Free Text Occupation (Spouse) } Free Text School (Child) } Free Text It is essential that as much information as possible is entered Casenotes (Screen 3) Select screen 3 <Enter>. Casenote Enter NEW Casenote number MUST include prefix letter(s). PMI Add and Revise VN

15 Command Allocated Defaults to ADD <Enter>to accept. Enter date Casenote number issued, <Enter> (Default today s date). Location Usual home of Casenotes e.g. HRLM = Health Records Library at Mitchell Way, (F9 (Superhelp) will display possible choices). Also see Casenote Number Location Explanation List (page 17). Placed On Date notes made up usually same as allocated but could be a later date, <Enter> (Default today s date). Comments Free text. Status Defaults to Current <Enter>to accept, screen asks if you wish to enter any more numbers, e.g. microfilm numbers, etc., Y (Yes) or N (No) as appropriate. CHECK CAREFULLY THAT YOU HAVE ENTERED THE CORRECT CASENOTE NUMBER. THIS CAN HAVE SERIOUS IMPLICATIONS ON PATIENT CARE, E.G. UNABLE TO TRACE CASENOTES IF THE NUMBER IS NOT ENTERED CORRECTL PMI Add and Revise VN

16 6. REVISE DETAILS OF AN EXISTING PATIENT <PMI> 1. Find the patient in LIS. 2. Recall the patient in PMI Add/Revise. REMEMBER: Type L to quickly recall the last patient displayed. 3. Select appropriate number from the taskbar at bottom of screen to enter the section requiring amendments or additions No. 1 Revise Basic Details Change an Existing Address Ensure that you have CAPS LOCK switched on. 1. <Enter> through the Basic Details screen until the Extended Address and PMI Address boxes appear. 2. If the cursor is not in the first line of the Extended Address Box up arrow. 3. Press the F9 (Superhelp) key. Search for the new address using a method described on page 7 or page When the correct address is displayed select it with the highlight bar and <Enter>. This will add it to the Extended Address box. 5. <Enter> though the address boxes until the Basic Details screen is displayed. As you do so the new address and postcode will update in the PMI Address box. 6. If the required address cannot be found, having tried several different search combinations, delete all address details in the top (extended) address box by pressing the F2 key on each line. <Enter> to the lower address box and type in the address (including the postcode). If the system accepts the address but not the postcode, leave the postcode field blank, and complete a 'Missing Postcode Form' (sample on page 21). 7. At Address Move or Correction type C for correction, or M for move. CORRECTION is putting right errors (C). MOVE is recording a new Patient Address (M). 8. PMI Add and Revise VN

17 9. For an address MOVE you must insert the date of move. If the correct date is not known you must put in a date of at least 3 days before you are entering this change on the system (e.g. T-3). This ensures day end records information in the correct order. REMEMBER: The address does not automatically change on the Basic Details Screen until you have entered <Yes> at the Enter prompt. You may refresh the screen prior to this by pressing F7. REMEMBER: Maintain Postal Address does not relate to the address you have just entered. The Default is NO please ensure it stays at NO unless you have had further instructions. REMEMBER: It is essential we have a full address including postcode. NOTE: If you are correcting/changing an address you are prompted to update the Next of Kin address if required. This can still be updated in the registration screen if you prefer to do changes there Change of Surname 1. Overtype the existing surname. 2. <Enter> through the remainder of the screen (including the address boxes). 3. Type <Yes> at the Enter prompt. 4. Answer <Yes> to retain the original surname with the patient s record. NOTE: Previous surnames must be retained, unless amending a spelling error. PAS will retain the three most recent previous surnames No. 2 Registration Details This can be used to revise any GP/GDP/NOK and demographic details etc. As with changing an address when recording GP or GDP changes select either Correction or Transfer. For a transfer the date rule applies. If the correct date is not known you must put in a date of at least 3 days before you are entering this change on the system (e.g. T-3). This ensures day end records information in the correct order. CORRECTING is putting right errors (C). TRANSFER is recording a new GP or GDP (T). REMEMBER - if the GP or GDP is not on the System follow instructions on page No. 3 Casenotes The casenote screen allows additional casenote numbers to be added or revision to the details of an existing casenote number. The screen will display the existing casenote number (if only one number allocated). PMI Add and Revise VN

18 If nothing is displayed in the casenote number field use F9 (Superhelp) to list all casenote numbers. To ADD another number - overtype the casenote number if displayed or enter new number in field then complete details as required. To REVISE details only of an existing casenote number F9 (Superhelp) and select the casenote number and amend details as necessary, e.g. 1. Withdrawing Baby Number (B) - amend Location and Status. Continue to add new casenote number. 2. Updating A+E number only and NCI (no Casenotes issued) - amend Placed On date to reflect date folder made up and Location. See also casenote number location explanation list on page 17. If you are unsure on casenote numbering, etc. please contact Registration in Health Records Library No. 4 Episodes This is used as a display function only. Shows episodic details. Displays from most recent record at top of list. (See Episode Enquiry Episode Status Description list on page 19). PMI Add and Revise VN

19 7. MAINTAIN FUNCTIONS 7.1. Maintain Address History <MAH> This function is used to list previous addresses and to revise or delete an incorrect entry if necessary. NOTE: Be aware, if you amend a record in MAH there could be implications on the contract. If in doubt check it out Maintain GP History <MGH> This function is used to list previous GPs and to revise or delete an incorrect entry if necessary. NOTE: The current GP is not displayed here. NOTE: Be aware, if you amend a record in MGH there could be implications on the contract. If in doubt check it out Maintain Surname History <MSH> This function is used to view up to the THREE most recent surnames including the date that changes have been recorded. It is also possible to revise or delete incorrect entries. PMI Add and Revise VN

20 8. CASENOTE NUMBER LOCATION EXPLANATION LIST All Casenote numbers start with one or more alphabetical characters. These can tell you about the origination of that Casenote number. Prefix in Case Note No Column Code in Current Location Column Used by Comment Q HRLM Acute Casenotes issued at QAH and at any other acute location (2010 onwards). Notes are filed at Health Records Mitchell Way. S HRLM Acute Numbers were issued at St Mary s Hospital, Royal Hospital Haslar, RH HRLM Acute Emsworth Cottage Hospital, Gosport War Memorial Hospital, Havant EQ HRLM Acute War Memorial Hospital or Petersfield Community Hospital. The notes G HRLM Acute are now filed at Health Records Mitchell Way. HW HRLM Acute PQ HRLM Acute Any of NCI Acute No Casenotes Issued. Some departments issue Casenote numbers the above but do not make up an actual Casenote folder as they have nothing to go in it. For subsequent activity when a folder is required - DO NOT ISSUE ANOTHER CASENOTE NUMBER. Request the folder from Health Records Library. Enter the PMI Add & Revise function and change Casenote Location as appropriate, e.g. QAH. J LSJ Community Number created and notes filed at Medical Records St James s Hospital. These notes are used to record mental health and community services activity. J Various Community Number created at St James s Hospital but notes filed at location where patient is a long term patient ie Mental Health Clinic. * QE QER Eye Eye Department Notes Only. Department * R RTD Radiotherapy/ Oncology Radiotherapy Notes Only. * These are separate numbers from General Hospital Casenote Numbers which are used for recording some activity within these departments eg Outpatient Appointments. If the patient is on the PMI with only a QE number or R number number DO NOT register on PMI again, just add the required Casenote Number on to the existing registration. Any IMG or MF Do not use Imaged/Microfilmed. Notes which are digitally imaged or Microfilmed. The status is withdrawn and date this took place (if known). NB: Imaging has now superseded microfilming notes. Any MER Do not use Merged. If two sets of notes are merged together the number which is no longer used must be merged on PMI. Only specified people have access to merge notes. Change location to MER. Ensure status is withdrawn and date this took place. H HREF Do not use Notes used at Haslar prior to amalgamation. Do not use to record information as they are for reference only. B REG Do not use Birth registration only. Registered on the system when the baby is born. If the baby /child attends after this a Hospital Casenote Number must be made up and used. REG (baby number) status to be changed to withdrawn. GPN GPN Do not use Casenote number originally issued by a GP when fast tracking a PMI Add and Revise VN

21 Prefix in Case Note No Column Code in Current Location Column Used by Comment patient referral through GP links or Choose and Book. Episodes using this number should be revised to use the Acute casenote number. IW IOW Do not use Isle of Wight Casenote Numbers - Not used for patient activity here. If required add Portsmouth Number to existing PMI Registration. CC COM Occupational Therapy CF COM Child & Family Therapy CH COM Podiatry DE COM Dental LD COM Learning Disabilities DN COM District Nurses EP COM Elderly Mental Health FP COM Family Planning PN COM Psychiatric Nurses PT COM Physiotherapy SN COM School Nurses ST COM Speech Therapy VH COM Health Visitors These numbers are used for Community Services only. They are in fact barcode records and not actual case note folders. They should NOT be used to record PHT or AMH activity. PMI Add and Revise VN

22 9. EPISODE STATUS DESCRIPTION IP ADM - Current Inpatient IP SUSP - Patient out on home leave DSCH INCPT - Inpatient Discharged - Coding Incomplete DSCH CMPLT - Inpatient Discharged - Coding Complete DIED INCPT - Inpatient Died Coding Incomplete DIED CMPLT - Inpatient Died Coding Complete A+E ATN - Accident & Emergency Attendance WL ACTV - Patient on Inpatient Waiting List WL DEFER - Patient on Deferred Inpatient Waiting List WL SUSP - Patient on Suspended Inpatient Waiting List WL CANC Patient Cancelled from Inpatient Waiting List CEA - Cancel Treatment - Elective Add. CEA may appear under the status on some episodes, this is to indicate the patient was Admitted and Discharged without having had treatment and is placed back on the Waiting List. PRE ADM TCI - Pre-Admission - To Come In - Date Offered PRE ADM - Pre-Admission Cancelled CANC PRE *** - Pre-Admission Date Past - Patient Not Admitted OP REG - Outpatient Appointment Episode OP DSCH - Discharged from Outpatients WA ATT - Ward Attender Attended WA EXP - Ward Attender Expected WA CNC - Ward Attender Cancelled WA DNA - Ward Attender - Did Not Attend WA WLK - Ward Attender - Walked In WA *** - Attendance Date Passed - Outcome not Recorded SG REG - Service Group Referral SG DSCH - Discharged from Service Group SG - Indicates a Patient Contact attached to the Service Group Referral IP SUMM - Isle of Wight Use Only (Inpatient Summary) OP SUMM - Isle of Wight Use Only (Outpatient Summary) PMI Add and Revise VN

23 10. SPECIALITY CODE LIST 100 General Surgery 401 Clinical Neuro-Physiology 101 Urology 410 Rheumatology 102 Transplant Surgery 418 Convalescent 103 Breast Surgery 419 Pre-Convalescent 104 Colorectal Surgery 420 Paediatrics 105 Hepatobiliary & Pancreatic Surgery 421 Paediatric Neurology 106 Upper Gastrointestinal Surgery 426 Special Care Baby Unit 107 Vascular Surgery 427 Neonatal Intensive Care Unit 109 Renal Surgery 430 Geriatric Medicine 110 Trauma & Orthopaedic Surgery 450 Dental Medicine Specialties 120 ENT 501 Maternity 130 Ophthalmology 502 Gynaecology 140 Oral Surgery 506 Infertility 141 Restorative Dentistry 510 Maternity Ante Natal 142 Paediatric Dentistry 520 Maternity Post Natal 143 Orthodontics 528 Well Babies 150 Neurosurgery 560 Midwife Maternity Event 156 Spinal Injury 610 GP (Maternity Function) 160 Plastic Surgery 620 GP (Other) 166 Burns Unit 628 GP (Dental) 170 Cardiothoracic Surgery 700 Mental Handicap 171 Paediatric Surgery 710 Mental Illness 176 Cardiac Surgery 711 Child & Adolescent Psychiatry 177 Thoracic Surgery 712 Forensic Psychiatry 180 Accident & Emergency 713 Psychotherapy 190 Anaesthetics 715 Old Age Psychiatry 199 Pain Relief 716 Adolescent Psychiatry 300 General Medicine 717 Child Psychiatry 301 Gastroenterology 719 Alcoholic Unit 302 Endocrinology 728 Drug Dependency 303 Haematology Clinical 729 Elderly Mental Illness/Health 304 Clinical Physiology 738 Child Assessment 305 Clinical Pharmacology 758 Child Psychiatry Group Contact 306 Haemophilia 800 Radiotherapy 307 Diabetic Clinic 810 Radiology 308 Bone & Marrow Transplantation 820 General Pathology 309 Haemophilia 821 Blood Transfusion 310 Audiological Medicine 822 Chemical Pathology 311 Clinical Genetics 823 Haematology 312 CL.Cytogenic / Molecular Genet 824 Histopathology 312 Clinical Immunology & Allergy 830 Immunopathology 314 Rehabilitation 831 Medical Microbiology 315 Palliative Medicine 832 Neuropathology 318 Unit For Younger Disabled 841 Metabolic Medicine 320 Cardiology 900 Community Medicine 326 Pacemaker 901 Occupational Medicine 330 Dermatology 990 Joint Consultant Clinic 340 Thoracic Medicine 4301 Elderly Acute 350 Infectious Diseases 4302 Acute Stroke 360 Genito-Urinary Medicine 4303 F/S Stroke Rehab 361 Nephrology 4304 Slow Stream Stroke Rehab 370 Medical Oncology 4305 General Rehab 371 Nuclear Medicine 4306 Continuing Care 376 Paediatric Oncology 4307 Shared Care 377 Oncology Continuing Care 4308 Post Acute 400 Neurology PMI Add and Revise VN

24 Portsmouth Hospitals NHS Trust, Primary Care Trusts, Portsmouth City, East Hants, Fareham & Gosport 11. PAS MASTERFILES REQUEST FOR POSTCODE Please print all information as writing cannot always be deciphered Postcode (max 10 char) Health Authority Code (max 4 char) Patient Details Casenote Number Patient Name Patient House No & Road District Town County Requester s Full Name Asset No (KB No) Department Full Address Telephone Ext Please send/ completed form to: Ict.servicedesk@iphis.nhs.uk Fax: For Office Use Only: Date Receive PMI Add and Revise VN

25 Portsmouth Hospitals NHS Trust, Primary Care Trusts, Portsmouth City, East Hants, Fareham & Gosport 12. PAS MASTERFILES - REQUEST FOR GENERAL PRACTITIONER (GP)/ SURGERY Please print all information as writing cannot always be deciphered GP Full Name (including any middle names) Surgery Address Postcode Telephone Number GP Code Practice Code Organisation Code PATIENT NAME AND CASENOTE NO (Must be entered) Name Casenote Number D.O.B Requester s Full Name Asset No (KB No) Department Full Address Telephone Ext Please send/ completed form to: Ict.servicedesk@iphis.nhs.uk Fax: For Office Use Only: Date Received: PMI Add and Revise VN

26 Portsmouth Hospitals NHS Trust, Primary Care Trusts, Portsmouth City, East Hants, Fareham & Gosport 13. PAS MASTERFILES REQUEST FOR DENTIST Please print all information as writing cannot always be deciphered Full Name (including any middle names) Surgery Address Postcode Telephone Number GDP Code PATIENT NAME AND CASENOTE NO (Must be entered) Name Casenote Number D.O.B Requester s Full Name Asset No (KB No) Department Full Address Telephone Ext Please send/ completed form to: Ict.servicedesk@iphis.nhs.uk Fax: For Office Use Only: Date Received: PMI Add and Revise VN

27 14. AUTO POSTCODING HELP SHEETS Ways of Searching Searching using F9 (Superhelp) Key On the line labelled Extended press the Key F9 (Superhelp) and enter the chosen address details on the search line. Option 1 Search using house number & Postcode 1. Enter the house number followed by a comma and then the postcode, e.g. 53,GU16 6BJ then press <Enter> past postcode 2. The complete address will be entered for you check that this is correct. 3. Press <Enter> until you return to the Basic Details Screen. 4. At the Enter prompt type: Y (Yes) to record patient s address. Option 2 Searching using Postcode only 1. Enter the postcode you wish to search on then press <Enter> past postcode. 2. A screen will be displayed showing all the addresses which match that postcode. 3. Scroll through the list using the page down and/or down arrow key until the one you require is highlighted. 4. When the correct one is highlighted, press <Enter> to enter the address. 5. The complete address will be entered for you check that this is correct. Option 3 Searching using house name and town 1. Enter the house name followed by a comma and the name of the town. e.g. Meadowlands, Waterlooville, and then press <Enter> past postcode. 2. The complete address will be entered for you check that this is correct. Option 4 Searching using street name and town 1. Enter the name of the street followed by a comma and the name of the town, e.g. Langstone Road, Portsmouth, then press <Enter> past postcode PMI Add and Revise VN

28 2. A screen will be displayed showing all the addresses which match that postcode. 3. Scroll through the list using the page down and/or down arrow key until the one you require is highlighted. 4. When the correct one is highlighted, press <Enter> to enter the address. 5. The complete address will be entered for you check that this is correct. Option 5 Searching using house number and street name 1. Enter the house number followed by a space followed by the name of the street, e.g. 96 Langstone Road, then press <Enter>past postcode. 2. A screen will be displayed showing all the towns, which have a street of that name. 3. Scroll through the list using the page down and/or down arrow key until the town you require is highlighted. 4. When the correct one is highlighted, press <Enter> to enter the address. 5. The complete address will be entered for you check that this is correct. Option 6 Searching using whole address without postcode. 1. Enter address as usual, press <Enter> to Postcode field, press <Enter> and the postcode for the address will appear. 2. The complete address will be entered for you check that this is correct. Option 7 Military Addresses 1. Press Key F9 (Superhelp). Enter name of barracks / regiment or base followed by name of town, e.g. H M S Collingwood, Fareham (H[space]M[space]S[space]) Royal Air Force, Farnborough Royal Army Medical Corps, Aldershot Roberts Barracks, Salisbury Ministry of Defence, (name of town if known) At Sea/In the Air this gives pseudo postcode - up arrow and type in the correct address e.g. H M S INVINCIBLE, followed by BFPO No. (If known). NOTE: BFPO gives nothing if this is the only info entered. PMI Add and Revise VN

29 2. Press <Enter> to enter the address. The complete address will be entered for you check that this is correct. NOTE: It will not always be easy to find military addresses. Do your best, if you cannot find the postcode address, type in all you know in the bottom box and leave the postcode field empty, but you MUST complete the missing postcode form (Page 24). Option 8 Foreign Countries There are two ways of searching for addresses outside the UK. 1. Type in name of country, e.g. France. 2. Press <Enter> through the Postcode field and the postcode will appear. 3. Arrow back up to top of the Extended Address box and type in the full address. Or 1. Press <Enter> until you reach postcode. 2. Press Key F9 (Superhelp). 3. Enter name of country. 4. Press <Enter> to accept postcode. 5. Arrow back up to the top of the Extended Address box and type in the address. Option 9 No Fixed Abode 1. Type: NO FIXED ABODE. 2. Press <Enter> through the Postcode field and the postcode will appear. 3. The complete address will be entered for you check that this is correct. NOTE: If there is an existing postcode from a previous address you must delete it using the F2 key to ensure the no fixed abode postcode is entered Other Tips The + symbol at the side of an address means there is additional information available. For example if you highlight and then press <Enter> on: PMI Add and Revise VN

30 + Without building name, Oxford Road, Gerrards Cross the following would be displayed: SL9 7DP French Horn, Oxford Road, Gerrards Cross SL9 7DP One Stop Community Store, Oxford Road, Gerrards Cross It is also possible to use the symbol * at the end of your search criteria to increase the area of your search. For example Nursery* would find: Nursery Gardens, Nursery Close, Nursery Road, etc. If your search criteria is unsuccessful, hit Previous Field Key (F6) and try a different search. If amending details on the front screen, but not the address field Page Down will move you quickly through the address fields. If the auto postcoder cannot find an address with your spelling it may provide an alternative TAKE CARE it may not be the correct address. PMI Add and Revise VN

31 15. FAULT REPORTING From time to time you may experience problems with faulty equipment, software problems or access to the Patient Administration System (PAS) ie password non acceptance problems. To resolve your problem a call with need to be logged with the ICT Service Desk ICT Service Desk ict.servicedesk@iphis.nhs.uk Phone or SJH (7703) You will need to give the Service Desk certain information, so always ensure you have the following information available. They may need to know: Your Username. The KB Number of the equipment. This is found on a small label (usually red or blue) stuck to the equipment. The clinical system you were working on. The patient s details e.g. case note no. Exactly what you were attempting to do, e.g. log on, view a patient s results Out of office hours Contact the ICT Service Desk and leave a message on the answer machine. They will deal with the problem as soon as they can. Alternatively them. If you feel there is a major system problem contact the switchboard for them to contact the engineer on call ICT Training If you identify an error in this manual or think that it would be useful to include something that has not been covered, please contact ICT Training. ict.training@iphis.nhs.uk External Phone Internal Phone QAH (7700) 5867 PMI Add and Revise VN

32 16. HELP WITH USING PAS If you have only just attended the course and feel you may need additional support, help or advice, you can contact the ICT Training Office. * If you have not used PAS for more than 12 months you will be required to re-attend your training. ict.training@iphis.nhs.uk External Phone Internal Phone QAH (7700) 5867 PMI Add and Revise VN

33 17. ICT TRAINING CANDIDATE APPEALS PROCEDURE.. Candidates who are unhappy with any aspect of the end of course/test assessment decision should first discuss the problem with the ICT Trainer at the time of receiving the result. The reasons must be made clear by the candidate at this time. If the candidate is still unhappy with the result further discussion should take place involving the ICT Training Team Leader within 3 days of the course/test date. The ICT Training Department will keep a record of such discussion together with date and outcome. Where necessary the 1st marker will be asked to re-mark and the marking checked by the ICT Training Team Leader. It should be noted that if the candidate was borderline double marking should already have been undertaken. If this does not provide satisfaction the candidate may raise a formal appeal. Appeals will only be accepted if made in writing (not ) to the ICT Training Manager within 10 days of the candidate receiving their result, outlining clearly the circumstance of the appeal. The 1st & 2nd markers will meet with the Training Manager to consider if there are any aspects that should be taken into account in the candidate s performance. In some circumstances the candidate may be offered a re-test (e.g. hardware or software problems). If this is not the case and the result remains unchanged then the candidate may write to the ICT Training Manager (within 5 days of receiving the 3rd result) who will consider all evidence and circumstances of the appeal also taking into consideration responsibilities to the Trust and Data Protection Act to make a final decision. ICT Training, QAH, July 2011 PMI Add and Revise VN

34 18. VERSION CONTROL/LOG Manual PMI Add and Revise Version V 4.23 Date 17 th February 2012 Revisions New None Updated MPAC Address to: MDHU Portsmouth, Albert House, Queen Alexandra Hospital, Cosham, PO6 3LY. Verified by MDHU. Page 8 Manual PMI Add and Revise Version V 4.22 Date July 2011 Revisions New None Updated Added new header and footer to document and repaginated. Updated Information Governance document. Updated candidates appeal procedure. Page All 5 & 6 33 PMI Add and Revise VN