Patient Access & Data Management Policy
Policy Prepared by: / Chris Hudson -Liz Hewett – Clinical Service Manager A&E
Sally Turbutt, Clinical Information Manager
Authorised by: / Clinical Management Board
Status: / Approved
Version / 29 July 2003
Document Tracking Sheet
Patient Access & Data Collection Policy
Number / Status / Date of Issue / Issued/approved by / CommentsV4 / Approved / December 2001 / Clinical Management Board
V4.2 / Draft / December 2002 / Circulated for comment
V4.3 / Draft / March 2003 / Operation Group
V4.4 / Draft / May 2003 / Operation Group
V 6.4 / Approved / July 2003 / Operation Group
CMB
Contents
Page Nos
1. Introduction 4 - 5
2. PMI (Patient Master Index) Registration 6
3. Casenote Tracking 7
4. A&E Attenders 8 - 12
5. Outpatients 13 - 16
6. Inpatient and Day Case Waiting Lists 17 - 22
7. Inpatient Management 23 - 28
8. Bed Management 29 – 30
9. Professions Allied to Medicine 31 - 32
10. Day Hospital 33
11. Community Assessment & Rehabilitation Team 34
12. Appendix 1 35
1 Introduction
1.1 Overview
Across business and industry it is recognised that reliable information is vital to the success of an organisation. This is also true in the NHS, where every decision, because they all impact ultimately on patient care, should be an informed evidence based decision. Our evidence – about the people we serve, their health and healthcare needs, depends on the availability of complete, accurate, relevant and timely data.
For years the NHS has tried to ensure that all data is accurate but with limited success. It is only now with Clinical Governance and the need to have reliable data, which is readily available, that it has climbed to the top of everyone’s agenda.
Clinical Governance is a framework designed to help healthcare professionals improve clinical standards and has emphasised the importance of good data quality within the NHS. Trusts have often been criticised unfairly for poor clinical performance when the reality is that data quality is weak and therefore gives an inaccurate picture of performance.
As individuals become accountable for clinical practice they will rely on the data to accurately reflect their position in order that they might, if necessary, defend it appropriately.
1.2 Policy Objectives
East Kent Hospitals Patient Access and Data Management Policy is intended as a user-friendly guide to patient management along with the definition, collection and interpretation of the nationally agreed data standards in the NHS. It describes the protocols for treating patients, data required, its definition and the timescales for collection and recording.
As the Trust moves towards standardising patient management and computer systems, it is important that data definitions and collection processes are consistent at each of the hospital sites, ensuring that we meet the standards for Data Accreditation[1].
The majority of data collected is directly related to patient care. This includes a whole range of data including, personal demographics, hospital episodes, tests, examinations, operations performed, diagnoses and in the future clinical outcomes.
In order to understand the information collected there must be comprehension in the context in which it is used. The Department of Health (DoH) demands uniformity in the data collected and the way in which it is collected. If these standards are ignored then the Trust will be unable to analyse or communicate information in a meaningful way. Missing, incorrect, or incomplete data directly affects the provision of quality patient care.
We must all be clear about the importance of both maintaining data standards and the uses to which data will be put, from caring for patients to accounting for the services we provide.
1.3 Policy Management
Having a policy is only the first step to ensure standardisation of patient access and data collection. The Trust must be sure that, through routine audit and documented processing all patient activity is collected and recorded consistently.
In order to do this, the Activity Definition Sub Group (ADS) has been set up to monitor compliance of data collection with this policy and where appropriate, make recommendations for change.
As the Trust develops new services additional activity will need to be recorded. Therefore any ward/department wishing to record new activity or change the definition of existing activity will be required to present their proposals to the ADS. It is vital that any activity recorded meets the national definitions and reflects the resources required to deliver the care.
It is intended that minimal changes will be made to the policy. However, it is important to keep the document up to date in order to reflect the changing environment that we now work in and will therefore be updated on a quarterly basis. All changes/additions will be notified to staff.
2. PMI (Patient Master Index) Registration
2.1 Introduction
2.1.1 It is widely recognised that the effective delivery of healthcare within East Kent is identifying all records that exist for a single patient. The PMI is the linchpin for all other components of PAS and clinical information.
2.1.2 Duplicate registrations on the Patient Administration System (PAS) are an ongoing problem and can result in clinical risk if patients have more than one hospital number and casenote.
2.1.3 Another area of clinical risk is missing information from patient registrations, for example, the patient’s full name and address, patients GP, telephone number etc. All of these are vital for all patients. If a patient needs to be contacted urgently accurate up to date information is essential.
2.2 Patient Registration
2.2.1 Each patient must have a unique PAS generated number. All subsequent casenotes will use the single hospital number.
2.2.2 The new NHS Number must be used as the primary sources of search where
Known.
2.2.3 All fields on PMI registration must be completed and where possible checked with the patient. Patient confidentiality need not be breached when asking the patient to confirm details.
2.2.4 Whilst the Trust operates three PAS systems, each PMI registration must include the existence of registrations on each of the other systems. Health Records will ensure that
2.3 Data Entry Standards
Requirements for Data Entry
¨ ALL data must be entered in upper case (Capitals).
¨ All patient demographic details should be checked, including spelling.
¨ Where any of the free text comment fields are used the information captured must be meaningful to all users
¨ IF YOU ARE UNSURE ABOUT ANY OF THESE DATA ENTRY STANDARDS YOU MUST CONTACT THE APPROPRIATE APPLICATION MANAGER.
2.4 Casenote Tracking
2.4.1 The importance of electronically tracking casenotes is paramount in the effective delivery of healthcare within East Kent. Through the correct use of the Casenote Tracking module (CNT) of PAS, it ensures that health professionals have the relevant information to provide appropriate treatment to patients at the point of contact, thus minimising clinical risk.
2.4.2 To guarantee the effectiveness of CNT the following Standards must be met by all staff:
· All movements of casenotes are to be recorded electronically
· Data entries are to be accurate and complete
· Movement of casenotes is to be made as soon as possible following data entry.
· All out of hours and/or PAS downtime data to be entered at the earliest opportunity.
· All staff who borrow notes will be responsible for their safekeeping.
· Once casenotes are loaned from the Library by Health Records, all transfers are to be recorded by the individual transferring the casenotes.
Administrative Guidance Notes exist to support the accurate management of the following functions:
Section G
· Dealing with filing of late arriving investigation results/correspondence
· Filing within casenote folder
· Living wills and advance directives
· Loose filing
· Management of fat files
· Merging of multiple casenotes
· Patients who want to access their own hospital records
· Inappropriate filing within casenote
· Guidance for transporting personal information
· Guidance for sharing personal information
3 A&E Attenders
3.1 Introduction to A&E Attenders
3.1.1 East Kent Hospitals considers the accurate data capture of all A&E Attenders to be critical for the monitoring of all emergency activity within the Trust. It is vital for the planning of emergency services that there is a clear understanding of how many patients are treated annually as well as the route by which they arrived.
3.1.2 There is also a requirement to measure the quality of care given to all patients attending the A&E and Minor Injury departments. The quality of care is measured in the main by the length of time patients wait for the different stages of their treatment, from triage through to waiting for a hospital bed.
3.1.3 There are currently three different systems in place to capture A&E activity data, however all of them will capture the key data items required by the Trust.
3.1.4 All patients must be registered on the local A&E System at the time of their arrival in the department regardless of route of arrival or medical condition, this includes babies born in the department.
3.1.5 Patients who are unable to identify themselves are to be recorded as unknown until further information can be gained.
3.1.6 Any patient who has died by the time they arrive at the Trust, but has not been certified, should be recorded as an attendance.
3.2 Data Definitions
3.2.1 Arrival Mode – This is the means by which a patient arrived at the hospital, for example by ambulance or other means.
3.2.2 Priority – 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.
3.2.3 Source of referral – The person or agency that has sent the patient to the department e.g. Self referral, GP, Expected
3.2.4 Initial Assessment Time (Triage Time) – The time a patient is assessed by medical or nursing staff in an A&E Department to determine priority for treatment. The assessment should be conducted by medical or nursing staff who have received appropriate training in triage.
Patients requiring immediate treatment will be treated immediately and triage time will be assumed as time of arrival in the department.
3.2.5 Patient Group – A coded classification to identify the reason for an A&E Episode.
3.2.6 Incident Location – The type of place where the incident occurred which led to an A&E Episode. This applies to trauma and accident cases only.
3.2.7 Time seen for treatment – The time, recorded using the 24hours clock, that the patient was seen by a health professional to diagnose the problem and arrange or start tests and treatment as necessary.
3.2.8 Attendance disposal – The way the patient attendance was concluded.
3.2.9 Attendance category – An indication of whether a patient is making first or follow up attendance at a particular A&E Department.
Note: An attendance at a consultant clinic following an A&E Attendance is an outpatient attendance even if the clinic is held by the A&E consultant in or near the A&E Department.
3.2.10 Attendance conclusion time – The time, recorded using a 24-hour clock that a patient’s A&E attendance concludes.
3.2.11 Staff member code – A locally determined code used to identify the person principally responsible for the care of the patient during an A&E attendance. In the majority of cases this will be the person who took responsibility for the discharge of the patient. Alternatively initials of the staff member can be used.
3.2.12 Decision to admit - All admissions to hospital are initiated by a Decision to Admit. This is a clinical decision, usually made by medical staff on behalf of the hospital. It indicates that the patient is intended to be admitted either as an urgent admission, or at some time in the future, as a routine admission.
3.3 A&E Registration of attendance
3.3.1 Each patient must be recorded on the local A&E System within 15 minutes of arrival, regardless of route of arrival or medical condition.
3.3.2 If a patient cannot identify themselves (they are unconscious or disoriented) they should be recorded as Male Unknown or Female Unknown. Once the patient’s identity is confirmed the details must be amended correctly.
3.3.3 If a patient cannot identify themselves, and the A&E system is ‘down’ the patient must be recorded in the manual register and given a new Hospital Number from the sequential list. When the system has been restored, the patient must be registered with the manual number. Health Records must be notified so that if a duplicate registration has been created the numbers and casenotes can be merged.
3.3.4 Every effort should be made to ensure that the patient has not attended the hospital on a previous occasion before creating a new registration in order to minimise clinical risk.
3.3.5 For all new registrations follow instructions in section 2. A&E Reception staff must ensure that all demographic details are captured and checked by/with patient.
3.3.6 A casualty card to be created (printed) for each patient following registration and passed to/electronically sent to appropriate member of staff for triage.
3.4 A&E Triage & Treatment
3.4.1 All patients must be triaged within 15minutes of arrival in A&E Department. Time of triage and priority to be recorded on local A&E System. For patients arriving by ambulance the triage time must be on arrival or within 15 minutes of arrival in the department.
3.4.2 The triage nurse will request the A&E card to be printed in the appropriate streamed area, e.g. majors, minors, paeds.
3.4.3 Patients casenotes must be requested by A&E Staff from the local Health Records department at the time of notification from the Bed Bureau.
3.4.4 The time the patient is assessed by the doctor for treatment must be recorded on the local A&E System in real time.
3.4.5 On completion of treatment the time of discharge and disposal code must be recorded on the local A&E System.
3.4.6 All investigations and treatments to be recorded on patient casualty card, and where applicable on local A&E System.
3.4.7 A discharge letter must be completed for every A&E attendance giving reason for attendance, treatment given and follow up information. A copy to be sent or emailed to patient’s registered GP.