Social Services (SOC)

Transcription

1 Patient Administration System Social Services (SOC) Version 1.1 August 2011 IT Training Ground Floor, Rodney Road Centre, Portsmouth. PO4 8SY Tel: Option 3 it.training@porthosp.nhs.uk Website: IT 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. IT 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 IT Training website. All references made to patient records are fictitious for the purpose of training only. Social Services OCM VN1.1

2 CONTENTS 1. GENERAL COURSE INFORMATION INFORMATION GOVERNANCE What can you do to make Information Governance a success? CONFIRMATION OF DETAILS PROCEDURES KEYBOARD LAYOUT Primary keys and their function Function Keys - F Key Set HOW TO LOG ON Logging on for the first time Subsequent logging on CROSS SITE ACCESS How to change hospital code REVISE ORDER STATUS <ROS> REPRINT TRANSACTION <REP> ORDER TRANSACTION D/T LOG PMI LIST <LIS> Basic guide SEARCH PROCEDURES Recommended search procedure Other search methods Help list PATIENT EPISODE ENQUIRY <EPI> DISTRICT WIDE INPATIENT NAME ENQUIRY <NID> INPATIENT NAME ENQUIRY <NI> SPECIALITY CODE LIST Introduction Description of episode types List of definitions EPISODE STATUS DESCRIPTION FAULT REPORTING IT Service Desk Out of office hours IT Training Social Services OCM VN 1.1

3 18 HELP WITH USING PAS IT TRAINING CANDIDATE APPEALS PROCEDURE VERSION CONTROL/LOG Social Services OCM VN 1.1

4 Patient Administration System (P.A.S) Course 1. GENERAL COURSE INFORMATION COURSE TITLE METHOD OF TRAINING DURATION PRE-REQUISITES ORDER COMMUNICATIONS SOCIAL SERVICES (SOC OCM) Classroom 3 hours None, although Keyboard Skills advisable. ABOUT THE COURSE The Patient Master Index holds general patient information. Attending this course will enable the student to revise the Status of a Social Services Referral using PAS in accordance with Trust requirements and Information Governance regulations. SUITABLE FOR Social Services Staff OBJECTIVES This course will enable the student to: 1. Display knowledge of their responsibilities for Data Protection and the Caldicott Principles. 2. Log on and off of the P.A.S. system. 3. Revise the status order of a referral. 4. Reprint a referral. 5. Print OTL. 6. Find and select a Patient. 7. Identify specific information, e.g. GP, Case note Number, etc. 8. Select specific episodes to identify information. 9. View lists of current inpatients. Social Services OCM VN 1.2 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 IT 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. Social Services OCM VN 1.2 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 Social Services OCM VN 1.2 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: IT 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. Social Services OCM VN 1.2 4

8 4. KEYBOARD LAYOUT 4.1. Primary keys and their function 1. RETURN or ENTER Must be pressed at the end of each entry you make. It tells the computer that you have finished typing the prompted keystroke. 2. BACKSPACE Used to delete the last character typed. Repeated pressing deletes characters to the left. This key can only be used for correcting errors BEFORE pressing the RETURN/ENTER key. 3. DELETE (DEL) Can be used as a BACKSPACE key. Can also be used in conjunction with arrow keys to re-enter a word to delete an individual character. 4. ARROW KEYS Can be used to move selection highlight/cursor around the screen. They allow movement up, down, (left and right on menu only). Can also be used to re-enter a word, and to amend if necessary. 5. SHIFT To produce the upper symbol of dual character keys and upper case letter characters. 6. CAPS LOCK To produce upper case alphabetical characters only without having to use the shift key. Does not affect the upper symbol keys. Pressing key ON will display light on right hand side of keyboard or display words CAPS LOCK in corner of screen, dependant on the type of computer terminal being used. Pressing key again will release CAPS LOCK. 7. PAGE UP and PAGE DOWN Used to move back and forward on lists, which extend further than the screen space allows. E.g. If display prompts do you want NEXT page, use the page down key, to go back again use the page up key. 8. NUMERIC KEYPAD Numeric pad to right of keyboard. May be used instead of the number keys above the letter keys. Pressing NUMBER LOCK (NUM LOCK) key will display light on right hand side of keyboard above the numeric pad. Pressing key again will release NUMBER LOCK. IMPORTANT NOTE: CAPS LOCK MUST BE OFF WHEN LOGGING ON TO THE SYSTEM. Social Services OCM VN 1.2 5

9 CAPS LOCK MUST BE ON ONCE YOU ARE LOGGED IN Function Keys - F Key Set F key functions could be different depending on the program being used. Use of F keys within P.A.S. (Patient Administration System) F1 = Exit F2 = Delete Field F3 = Go To First F4 = Go To Field F5 = Go To Page F6 = Previous Field NB: Also used to change function set and change hospital code. F7 = View (Refreshes screen) F8 = HELP (explain and advice) F9 = SUPERHELP (selection lists) F11 = Multi-Select (Allows selection of more than one item in a list, certain functions only) Social Services OCM VN 1.2 6

10 5. HOW TO LOG ON Upon completion of training and ensuring that you are confident and competent in the use of the system, the trainer will send an authorisation form to the PAS Applications team asking them to set up your account. You will then receive notification from them giving you your USERNAME and instructions on how to complete the initial log on. If you have not received these instructions after 5 working days following the course, please contact the IT Service Desk (see contact numbers on Page 17). 5.1 Logging on for the first time Due to the variation of computer equipment being used within the Trusts log-in procedures can differ between areas. Check with your area what yours entails. NOTE: If using a PC or Thin Client you must have an NT account set up. Ask your manager to ensure that this is arranged. Having selected PAS, at the prompt: Login: Type in prd <Return> When you are asked for the USERNAME, type in the PAS Username you have been allocated by the Applications team, (usually your surname and initial or combinations of them), and then press Enter At the prompt: Password: Type in the word password <Return> The screen will then indicate that this has expired and ask you to type in a new password. This is where you type in the password that is only for your use and MUST NOT be shared with anyone, (see Information Governance page 2). You will then be asked to type it in again as verification. Passwords can be a combination of letters and numbers but must not be less than 6 or exceed 12 characters. If you have been given access to record information for more than one site you will then be asked to enter the Hospital Code you wish to record for, e.g. QAH, SMH. Social Services OCM VN 1.2 7

11 5.2 Subsequent logging on For subsequent log-ins at the following prompts you will need to enter: Log in: prd (if required) <Return> Username: e.g. bloggsj <Return> Password: _ <Return> Hospital: (as appropriate) Your password lasts for 90 days; you will be warned that it is expire so you have time to think of a new one. If you have only been given access to Social Services OCM, upon login, you will be presented with the following menu screen:- If you forget your password or need to reset it, please contact IT Service Desk; see page 17. Social Services OCM VN 1.2 8

12 6. CROSS SITE ACCESS When you first log on you may be asked to enter a Hospital Code - type in either SMH or QAH (or other hospital code) whichever is appropriate for the activity you are dealing with/recording. You can also use the super help key (F9) to see a list of hospital codes that you have been given access to, and then select the code from this list. If you have computer access to more than one site e.g.: SMH & QAH (remember RHH is recorded at QAH), you can move from one to the other without completely logging out of the system. NOTE: When you are working in a selected function, the hospital you are logged in as will be displayed in the top right hand corner of the screen. 6.1 How to change hospital code Press F1 until you are on a menu screen, as per page 0. Press F6 until you are asked for the Hospital Code, enter the code required and you will get the first function set Menu, e.g. SOC, if this is not the function set required press F6 and select as usual. Remember - you could have different access at each site. If the menus look different e.g. more or less functions, it could be that you have logged onto the wrong hospital. If you have selected a particular patient to record activity against and then change hospitals you can still use the quick Recall facility by typing L for Last Patient Selected. Social Services OCM VN 1.2 9

13 7. REVISE ORDER STATUS <ROS> Ward staff will request inpatient social services referral using the ward based Order Communications function Set. Social Services staff will acknowledge these electronic referrals by revising the status order. Social Services Status Codes 36 Request Received 85 Referral Accepted 1. Select <ROS> 1. Using the District Number as printed on the top left hand side of patient referral, select the patient. NOTE: On the PAS screen this is the PAS number field. Social Services OCM VN

14 3. Select the relevant episode by the No. This will be the IP ADM (Inpatient Admission for the referring ward). The patients ward code is on the paper referral; look for this on the Select Episode Screen. 4. Enter the transaction number at the Select Transaction field. If you do not know this number F9 at Select Transactions and enter through all the fields until the Change Status Screen appears. Or Social Services OCM VN

15 5. The status will fault to the next logically status number:- 25 will default to 36 Request Received 36 will default to 85 Referral Accepted. NOTE: The Status numbers offered will be different dependant on whether you are viewing an Assessment Notification / Expected Discharge / Discharge Notification or a De-notification of Discharge. 6. F9 - to see all available Status Codes. 7. Press the enter key to the bottom of the Screen and enter Y for YES, to save your choice. Social Services OCM VN

16 8. REPRINT TRANSACTION <REP> If you need to reprint a copy of a Social Services Referral you will need to use the function <REP> Reprint Transaction. 1. Using the District Number (or as much of the following recommended search procedure as possible), search for your patient: Surname Forename Date of Birth Patient Sex In full Initial only Six digits M for Male / F for Female 2. Select your patient- if the recommended search procedure has been used. 3. Select the relevant Inpatient Episode. Social Services OCM VN

17 4. The following screen is displayed, enter through to the bottom of the screen. 5. Select the transaction you wish to reprint. 6. At the ENTER prompt type Y for Yes. You will then get a notification to say the document has been printed. Social Services OCM VN

18 9. ORDER TRANSACTION D/T LOG This function will enable you to print a log of referrals that have been requested whilst you have been out of the office. You may back day this to a maximum of three days. Remember to change Hospital Code if you require QAH & SMH referrals. Example Transaction Log Report PAS MANAGEMENT ORDER TRANSACTION LOG Page: 1 From 28/03/08 16:00 to 31/03/08 15:09 Order Entry Run Date:31/03/08 15:08 Number Name DOB Loc n Cons Spec Trans Start dt/time Order dt/tm Service Priority Curr Status Prev Status Update Q Fowler, Sally 26/06/1950 E4 AMW ASS NOTIF ROUTINE 85 REQUEST SENT Q Berry, Colin 10/02/1963 E4 AMW DISCH NOTIF ROUTINE 36 REQUEST SENT Q Greer, Richard 02/04/1950 E4 AMW DENOT CL UNST ROUTINE 25 REQUEST SENT Q Biddle, Anne 26/06/1950 E4 AMW EXP DISCH ROUTINE 25 REQUEST SENT 28/03/08 17:05 28/03/08 17:15 28/03/08 17:05 28/03/08 17: PMI LIST <LIS> The function <LIS> is the means to establish if a patient has had past contact with any of the Portsmouth Hospitals, the Community Services or the Isle of Wight. If they have Social Services OCM VN

19 then all or part details will be found on the PMI (Patient Master Index), searches can be made using various combinations of patient demographic information, i.e. surname and forename initial, date of birth or approximate age and sex, or any combination. If no matches are found, a list of similar sounding names may be made available to you. To ensure entries are not duplicated, use case note number only as a last resort Basic guide 1. Log on in the usual manner. 2. Select function <LIS> and press <RETURN>. 3. To search for the patient always start by using the recommended SEARCH PROCEDURE of surname, forename initial, date of birth, sex (see notes overleaf for other help/suggestions). Press <RETURN>. A list of possible matches will be displayed, e.g. Definitions of some of the symbols you may see in the Matching Patient Records screen: # indicates a surname the patient was previously known under. & indicates the preferred name to address the patient if different to their forename. * indicates the patient is recorded as deceased. 4. Select correct patient from list by entering the appropriate Sequence Number found on the left hand side of the screen. Press <RETURN>. The patient s basic details will be displayed. Check that they are correct and that you have the correct patient. Social Services OCM VN

20 NOTE: You must select the sequence number, even if only one patient is displayed on the screen. 5. For other details select from the taskbar at bottom of screen: 1. DETAILS 1 - Displays General Practitioner (GP) Details, Next of Kin, Religion, Marital Status, NHS Number etc. 2. DETAILS 2 Displays General Dental Practitioner (GDP) Details, Ethnic Origin etc. 3. CASENOTES - Displays case note number(s), base location of notes and status (current or withdrawn). 4. EPISODES - Displays all previous and current activity, attendances and episodes of care; e.g.: inpatient, outpatient and service group events, in reverse chronological order (most recent dates are at the TOP of the list). Press relevant number for information required, then <RETURN>. Further details will be displayed. 6. Press F1 to exit <LIS>, or <Enter> to return to the Search screen. PLEASE ENSURE THAT YOU READ THE NEXT PAGE Social Services OCM VN

21 11. SEARCH PROCEDURES 11.1 Recommended search procedure The first search for a patient should always be by following the RECOMMENDED SEARCH PROCEDURE : SURNAME, FORENAME (Initial only), DATE OF BIRTH & SEX By using this method up to 90% of patients can be identified on the PMI Other search methods If only NAME AND DATE OF BIRTH available, press <RETURN> until the cursor reaches the Surname field. Type in surname <RETURN>, forename initial <RETURN>, date of birth <RETURN> (past postcode field) to end of screen. NOTE: Remember when using a date of birth the +/- field will only search on the year of birth not on the day or month. The default in the +/- field is 3 years, overtype to change (0-9). You could convert the DOB to an approximate age. This will search on all dates within the range. If NAME ONLY available, press <RETURN> until the cursor reaches the Surname field. Type in surname and forename initial. THINK: Use various combinations of information to ensure you do a full search of the PMI, and identify the correct patient. If a patient has a preferred name different to their forename and it has been recorded on their PMI record you will still be able to find the patient using their preferred name in the forename field. NOTE: Do not search using the postcode even if this is combined with other details. CASENOTE NUMBER ONLY - type in the Case note Number in the relevant field, press <RETURN>. REMEMBER: if searching by case note number the system will find anything under this number, even if the case note number has been withdrawn from use. You must access the case note selection of the patient record to check current live number is used. Also, if searching by case note number this will not show possible double registrations, therefore search by case note number should only be used in special circumstances. PAS NUMBER ONLY - type in the PAS Number in the relevant field, press <RETURN>. NHS NUMBER ONLY type in the NHS Number in the relevant field, press <RETURN>. MILITARY NUMBER ONLY type in the Military Number in the relevant field, press <RETURN>. Social Services OCM VN

22 11.3 Help list When searching for a patient if you cannot find them using the Recommended Search Procedure remember to try various combinations of information. 1. Part surname - e.g. LEW for LEWKOWICZ. 2. Double-barrelled name - could be reversed, e.g. Warwick-Brown, Brown-Warwick. 3. Similar sounding names - e.g. Walters - Waters, Shepherd - Sheppard. 4. Forenames such as Kathryn, Katherine or Catherine. Is initial entered correctly? 5. Could Forename and Surname be reversed - e.g. Thomas Paul, Paul Thomas 6. Male and female versions of names such as Lesley / Leslie, Frances / Francis, Lee / Leigh / Lea. If the name has been spelt wrongly, another user may have amended the sex field to try to match the name, so you could try leaving the sex field blank. (F2 to delete field). Do not assume sex by forename, e.g. Kim, Charlie, Lee could be male or female. 7. Children could be registered as M-I (Male Infant) F-I (Female Infant) if they were not named at birth, or forename could have been changed after birth registration. 8. Child could have a different surname from parent. 9. Remember the Age +/- search only checks either side of the YEAR of the date of birth. Therefore, try checking on age only search. (Default is 3 years). ALWAYS BE AWARE OF THE SEARCH OPTIONS YOU HAVE. EVERY EFFORT MUST BE MADE TO AVOID DUPLICATED ENTRIES. REMEMBER: A patient s case notes on a shelf in Health Records does not help in the care of the patient - so search thoroughly. Social Services OCM VN

23 12 PATIENT EPISODE ENQUIRY <EPI> This function will make available to you detailed episode information on:- a. INPATIENT ADMISSIONS b. WAITING LIST EPISODES. c. OUTPATIENT REFERRALS. d. WARD ATTENDER EPISODES. e. ACCIDENT & EMERGENCY ATTENDANCES - front screen only f. SERVICE GROUP REFERRALS 1. Log on in the usual manner. 2. Search for patient in the <LIS> function. Select patient using sequence number (on left side of screen). Press F1 to exit back to the menu. 3. Select function <EPI> from the menu and press <Return>. Type L (for last patient selected) in any of the top 5 fields, this will bring the patient selected in <LIS> to the Episode Enquiry screen, e.g.: 4. For more detailed information of any episode, select your episode by sequence number, press <RETURN> and further episodic information will be displayed. 5. If the patient has not had any episodes, the screen will provide the message: 6. Press F1 to exit <EPI>. NO RELATED EPISODES FOUND PLEASE SEE PAGE 29 FOR EPISODE STATUS DESCRIPTION LIST Social Services OCM VN

24 13 DISTRICT WIDE INPATIENT NAME ENQUIRY <NID> This function enables the user to view details of patients currently in Hospital or discharged within the last 3 days. The system will search across all the hospitals in the local area, not just the hospital to which you are logged in. NOTE: Remember that this function searches all the hospitals in the area, so you may need to go through several screens in order to find the patient you are looking for. This very much depends on the search that you performed. 1. Select the function <NID>. 2. NAME Enter surname or part surname of patient. A list of patients matching the criteria you have requested will be displayed, e.g.: Status (Stat) of Stay: If blank, patient is still on ward. DSCI = Discharged, Coding Incomplete DSCC = Discharged, Coding Complete SUSP = Suspended Patient on Home Leave DECD = Deceased (* in Dead Column) 3. If no patient matching the criteria is found or selected the screen will display: Try again? Y / N. If Y (YES) entered will return to name prompt. If N (NO) entered you can Search on Pre-admission? Y / N. Or, Search on Waiting List? Y / N. Social Services OCM VN

25 This function can be used to find a patient and then recall them for any of the other functions available, e.g. transfer, discharge. 4. Select appropriate patient from list using the selection number on the left hand side of the screen. 5. The screen will now return to the main menu, e.g. LIS, EPI. Select appropriate function from menu. Type in the letter L (for last patient selected) in any of the top 5 fields and <RETURN>. The patient details will now appear on screen. 14 INPATIENT NAME ENQUIRY <NI> This function works in exactly the same way as function NID (as above). The difference is that in NI, the system will search only within the Hospital which you have logged in as, i.e. QAH / SMH. NOTE: RHH displays under QAH (RHH wards are shown with the letter Y at the beginning of the ward code). Social Services OCM VN

26 15 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 Social Services OCM VN

27 PATIENT ADMINISTRATION SYSTEM (PAS) DEFINITIONS 15.1 Introduction This paper is aimed at users of the PAS and intends to give the national definitions to some of the fields contained within the system. Also shown with some of the definitions are examples of the categories that should be collected. The categories will be the national written text, which may differ slightly to what is shown on PAS. These definitions have been extracted from the NHS Data Dictionary which is used by all NHS Trusts in one form or another. This enables all Trusts to collect the same details, in the same manner. For example, when a patient is discharged from hospital after an Inpatient episode, one of the fields to be completed is the Destination on Discharge. This records where the patient is residing after care. The majority of times the response in this field would be Usual Place of Residence (ie Home). But other options can be selected here such as: Penal Establishment, Court, Hospice and Temporary place of Residence. This list is not exhaustive, as there are many data items collected throughout the NHS. This list touches on some of the most common fields in PAS and hopes to give users the true definitions behind the information they are collecting. For those users, wishing to view the complete NHS Data Dictionary, this can be found on the Internet, using the following web address: Description of episode types Ward Attender Day Case Ordinary Admission Outpatient (Appointmen ts) Regular Day Admission Ward attenders are patients who come into a ward to receive nursing care, but have not been admitted to hospital and do not stay in the ward. They may need care because of diseases or injuries or other factors such as pregnancy that can affect their health. You need to record details about these patients since they use ward resources, such as staff time and other facilities. A patient admitted electively during the course of a day with the intention of receiving care who does not require the use of a hospital bed overnight and who returns home as scheduled. If this original intention is not fulfilled and the patient stays overnight, such a patient should be counted as an ordinary admission. A patient not admitted electively, and any patient admitted electively with the expectation that they will remain in hospital for at least one night, including a patient admitted with this intention who leaves hospital for any reason without staying overnight. A patient admitted electively with the intent of not staying overnight, but who does not return home as scheduled, should be counted as an ordinary admission. A series of out-patient attendances consultant will form a consultant out-patient episode, generated from a single referral. Note that it is possible to have two consultant out-patient episodes with the same consultant for different clinical conditions, if two referrals are made. A patient admitted electively during the day, as part of a planned series of regular admissions for an on-going regime of broadly similar Social Services OCM VN

28 treatment and who is discharged the same day. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the patient no longer requires frequent admissions Regular Night Admission A patient admitted electively for the night, as part of a planned series of regular admissions for an on-going regime of broadly similar treatment and who is discharged in the morning. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the patient no longer requires frequent admissions List of definitions Field Name on PAS (National Field Name) Dest on Discharge (Discharge Destination) Disch Date (Discharge Date) Meth of Discharge (Discharge Method) DT on List (Date of decision to Admit) Delivery Method Did Not Attend Reason Mode of Arrival (A&E Arrival Mode) New or Follow Up (A&E Attendance Category) Disposal (A&E Attendance Disposal) Type of Incident (A&E Location Type) Disposal DT (A&E Discharge Time) Description (Example of options available) The destination of a patient on completion of a Hospital Provider Spell, or a note that the patient died or was a still birth. (Usual Place of Residence, Hospice, Court) Date of discharge from Hospital Provider Spell. The method of discharge from a Hospital Provider Spell. (Died, On Medical Advice) The date a decision to admit was made The method by which a woman is delivered of a baby which is a registrable birth (Breech, Spontaneous vertex) This records the reason why a patient did not attend an outpatient clinic when an appointment had been made. This is also used when a patient did not attend other types of healthcare (i.e. Waiting List Admission, Healthcare Contact) The means by which a patient arrived at an Accident and Emergency Department. (Brought in by Ambulance, Other) An indication of whether a patient is making first or follow-up attendance at a particular Accident and Emergency Department. (First Attendance, Follow Up Attendance Planned, follow Up Attendance unplanned) A coding of the ways in which an accident and emergency attendance might end. (Admitted to hospital bed, discharged, Referred to Fracture Clinic) The type of place where the incident occurred which led to an accident and emergency episode The time recorded using a 24 hour clock that a patient leaves an Accident and Emergency Department after an accident and emergency attendance has concluded. Social Services OCM VN

29 Field Name on PAS (National Field Name) Tracking DT (A&E Initial Assessment Time) Category (A&E Initial Triage Assessment Category) Priority (A&E Patient Priority) Seen D/T (A&E Time Seen for Treatment) Seen D/T (A&E Treatment) Diagnosis (A&E Diagnosis) Meth of Adm (Admission Method) Booking Type (Admission Booking Type) Booking Type (Appointment Booking Type) Attendance D/T (A&E Arrival Date) Appt D/T (Attendance Date) Attend/DNA (Attend or Did Not Attend) Birth Length Birth Order Birth Weight Clinic Code Clinic Description (Clinic Name) Description (Example of options available) The time a patient not needing immediate treatment, is assessed by medical or nursing staff in an Accident and Emergency Department to determine priority for treatment. The assessment should be conducted by medical or nursing staff who have received appropriate training in triage. The category assigned to a patient as a result of an initial assessment by medical or nursing staff in an Accident and Emergency Department. The triage category is used to determine the PATIENT's priority for treatment. A priority communicated to the patient following assessment which determines the urgency with which the PATIENT will be treated. This is based on locally agreed triage categories The time, recorded using the 24 hour clock, that the patient is seen by a health professional to diagnose the problem and arrange or start tests and start treatment as necessary. A broad coding of types of treatment or guidance which may be provided to a patient as a result of accident and emergency attendances A broad coding of types of diagnoses which may be made as a result of accident and emergency attendances The method of admission to a hospital provider spell. (Waiting list, Booked, Planned, Emergency GP, Emergency A&E) A classification of the type of booking system used for the patient's admission. (Traditional Method, Partial, Full) An indication of the type of booking system used for allocating the out-patient appointment. The date of arrival of a patient in the Accident and Emergency Department. The date of an attendance, or appointment to attend, for example at a consultant clinic, nurse clinic, Accident and Emergency Department, or by a Ward Attender This indicates whether or not a person or patient attended for an appointment. If the patient did not attend it also indicates whether or not advanced warning was given. (Appointment Cancelled, Did not Attend, Patient Arrived Late and was not seen) The length of a baby at birth. This should be recorded in CMS and forms part of the neonatal clinical option. The sequence in which the baby was born, if part of a delivery having multiple births. The weight of a baby at birth. This should be recorded in grams. An identifier for a clinic. Normally related to a Condition, Consultant or Specialty The name of Out-Patient Clinic. The description for the Clinic code. Social Services OCM VN

30 Field Name on PAS (National Field Name) Date of Death (Death Date) Last Reviewed (Elective Admission Review Date) Removal Reason (Elective Admission Removal Reason) Reason Code (Elective Admission Suspension Indicator ) Removal Date (Elective Admission List Removal Date) Appt Type (First Attendance) Appt Type (Initial Contact) Intd Mgmt (Intended Management) Live or Still Birth Indicator Exp Adm Date/Time (Date Offered for Admission Date) Disposal (Outcome of Attendance) Pat Class (Patient Classification) Decision to Refer (Referral Date) Referral Date (Referral Request Received Date) Disabled (Registered Disabled) Sex (Sex) Source of Adm (Source of Admission) Initiator of Attendance (Source of Referral A&E) Description (Example of options available) The date on which a person died, as recorded on the Death Certificate. The date on which an elective admission list entry was last reviewed. This records the reason why a patient was removed from the elective admission list A reason for suspending an elective admission list entry. Date removed from the elective admission list. Removal may be due to admission to a hospital provider spell, death or other reasons. This indicates whether a patient is making a first or follow-up attendance. An indication of whether the face to face contact is the first occasion on which a patient is seen by the particular professional staff group service, or any staff group of the health care provider. This is the intended pattern of bed use for a patient, decided when the decision is made to admit. This only applies to patients on the elective admission list. An indicator of whether the birth was a live or still birth. A still birth is a birth after a gestation of 24 weeks (168 days) where the baby shows no identifiable signs of life at delivery. Date offered for admission to hospital to start a hospital provider spell. This records the outcome of an out-patient attendance consultant. (Discharged from Consultants Care, Another Appointment given, Appointment to be made at a later date) A coded classification of patients who have been admitted to a hospital provider spell. (Ordinary Admission, Day Case, Ward Attender) The date on which the referral was made, as recorded on the referral request. This records the date the referral request was received An indicator used to record whether or not an employee is registered as disabled. The sex of patients intended to use a ward or nursing home indicated in the operational plans (Male, Female, Either Sex) The coded source of admission to a hospital provider spell or a nursing episode when the patient is in a nursing home. A classification which identifies the source of referral of each accident and emergency episode. (GP, Self Referral, Work) Social Services OCM VN

31 Field Name on PAS (National Field Name) Ref By (Source of Referral Outpatients) Specialty (Specialty Code) Transport (Transport Arranged Indicator) Description (Example of options available) A classification which is used to identify the source of referral of each consultant out-patient episode. A unique code identifying each specialty designated by Royal Colleges. (General Surgery, Urology, Orthopaedics) An indicator showing whether transport has been arranged for the patient. (Yes, No) Produced by: IT Information Manager Issue Date: 03/02/03 Revision Date: 14/07/11 Social Services OCM VN

32 16 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) Social Services OCM VN

33 17 FAULT REPORTING From time to time you may experience problems with faulty equipment, software problems or access to the Patient Administration System (PAS) i.e. password non acceptance problems. To resolve your problem a call with need to be logged with the IT Service Desk IT Service Desk it.servicedesk@porthosp.nhs.uk Phone 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 IT 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 IT 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 IT Training. it.training@porthosp.nhs.uk Phone 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 IT Training Office. Social Services OCM VN

34 * If you have not used PAS for more than 12 months you will be required to re-attend your training. Phone Social Services OCM VN

35 19 IT TRAINING CANDIDATE APPEALS PROCEDURE 20 Candidates who are unhappy with any aspect of the end of course/test assessment decision should first discuss the problem with the IT Trainer at the time of receiving the result. 21 The reasons must be made clear by the candidate at this time. 22 If the candidate is still unhappy with the result further discussion should take place involving the IT Training Manager within 3 days of the course/test date. 23 The IT Training Department will keep a record of such discussion together with date and outcome. 24 Where necessary the 1 st marker will be asked to re-mark and the marking checked by the IT Training Manager. 25 It should be noted that if the candidate was borderline double marking should already have been undertaken. 26 If this does not provide satisfaction the candidate may raise a formal appeal. 27 Appeals will only be accepted if made in writing (not ) to the Head of Engagement & Delivery within 10 days of the candidate receiving their result, outlining clearly the circumstance of the appeal. 28 The 1 st & 2 nd markers will meet with the Head of Engagement & Delivery to consider if there are any aspects that should be taken into account in the candidate s performance. 29 In some circumstances the candidate may be offered a re-test (e.g. hardware or software problems). 30 If this is not the case and the result remains unchanged and the Training Manager is unable to resolve the impasse then the candidate may write to the Head of Engagement & Delivery (within 5 days of receiving the 3 rd 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. IT Training QAH April 2015 Social Services OCM VN

36 31 VERSION CONTROL/LOG Manual Version V.N 1.2 Date April 2015 Revisions Page Update All footers & headers All Update ICT changed to IT All Update Telephone number, and web address Various Manual Version V.N 1.1 Date [August 2011 Revisions Page Update All footers & headers All Social Services OCM VN