Accident and Emergency Procedure
Version:
Issue Date:
Version 3.0
Responsible Person:
Elin Williams
Assistant General Manager for Emergency Care
4th May 2004
Review Date:
4th May 2005
DO NOT USE THIS PROCEDURE AFTER THE REVIEW DATE
Contents
1 Introduction .................................................................... 4
1.2
Purpose ................................................................................................... 4
2 General Procedure ........................................................ 5
2.1
2.2
2.3
2.4
2.5
2.6
2.7
Unknown Patients .................................................................................... 5
Patients brought in by Ambulance ........................................................... 5
See and Treat .......................................................................................... 6
Locating a patient on the PAS ................................................................. 6
Overseas Patient ..................................................................................... 7
Multiple/Duplicate/Old Prefix records on the PAS .................................... 7
Updating Patient Details on the PAS ....................................................... 8
3 Booking in Patients ........................................................ 9
3.1
Patient Type ............................................................................................ 9
3.2
Booking in Review Patients ..................................................................... 9
3.3
Booking in Minor Operations (Crawley) ................................................. 11
3.4
Booking in Lodged Patients (East Surrey & Crawley) ............................ 11
3.5
Booking in New Attendances ................................................................. 12
(that have not previously attended the Trust) ................................................... 12
3.6
Booking in New Attendances (that have previously attended the trust) . 13
3.7
Booking in A&E Unplanned Follow Up Attendance ............................... 13
3.8
Recording Patients Attendance ............................................................. 14
3.9
Road Traffic Accident (RTA) .................................................................. 15
3.10 Disposing of Casualty Cards ................................................................. 16
3.11 Casualty Cards Administration .............................................................. 18
3.12 Filing Casualty Cards............................................................................. 19
3.13 Medical Assessment Unit (MAU) ........................................................... 19
4 Admitting Patients ........................................................ 20
4.1
4.2
4.3
4.4
Admitting a Patient to A&E Department ................................................. 20
Transferring Patient to Ward within the Trust ........................................ 24
Discharging a patient from the A&E Department ................................... 26
Transferring Patient to another Trust ..................................................... 27
5 Patient Referral Requests ............................................ 28
5.1
5.2
5.3
Dealing with Referral Requests ............................................................. 28
Booking Outpatient Appointments ......................................................... 29
End of day for review and Minor Ops..................................................... 32
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6 Case-Notes .................................................................. 34
6.1
6.2
6.3
6.4
6.5
6.6
Tracking Case-notes.............................................................................. 34
Case-note numbering ............................................................................ 34
Case-note structure ............................................................................... 35
Making up Case-notes for new patients................................................. 37
Temporary Case-notes .......................................................................... 40
Transporting Case-notes ....................................................................... 41
7 Security and Confidentiality ......................................... 42
7.1
Requests for Information ....................................................................... 42
8 Deceased Patients ....................................................... 43
8.1
8.2
Patients that are Dead on Arrival to A&E ............................................... 43
Patients who die in A & E ...................................................................... 43
9 Contacts ....................................................................... 44
10
Managers Procedures ............................................... 45
10.1
10.2
10.3
10.4
Sample Checking .................................................................................. 45
Dealing with Data Quality Reports ......................................................... 45
Completeness Report ............................................................................ 45
Case Note Tracking ............................................................................... 46
11
Appendices ............................................................... 47
Appendix 1 - Highlighting Possible Duplicates/Multiples/Old Prefix’s
Memo..................................................................................................... 47
11.2 Appendix 2 – Patient Update Details Form ............................................ 48
11.3 Appendix 3 - Application for Additional GP’s on the PAS ...................... 49
11.4 Appendix 4 – Recoding Patients Ethnic Category ................................. 50
11.5 Appendix 5 – Doctors Names and Identification Codes ......................... 51
11.6 Appendix 6 - ‘Non Urgent Case-note to be called’ ................................. 53
11.7 Appendix 7 – Fracture Appointment List (Example) .............................. 54
11.8 Appendix 8 - Review Clinic Appointment List (Example) ....................... 55
11.9 Appendix 9 - Case-note Tracking Slip ................................................... 56
11.10 Appendix 10 – Request for Personal Information ............................... 57
11.11
Appendix 11 – Casualty card Sample Checking Sheets .................... 59
11.1
Written By:
Elin Williams – Assistant General Manager for Emergency Care
Julie Reid – A&E Team Leader
Jackie Standford – A&E Receptionist
Lyndee Peters – Data Quality Manager
Nicola Gould – Data Accreditation Facilitator
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1
Introduction
1.1.1
The Accident and Emergency Department provides care to patients
who arrive following an accident or with an emergency medical
condition. In the case of serious injury or accident, the treatment
offered by the department will consist of vital resuscitation or other
essential care before the patient is admitted to a hospital bed.
1.1.2
Patients’ either refer themselves to the Accident and Emergency
Department or have been seen by their GP (General Practitioner) first.
In the latter case, the department is used as the admission point for prearranged admissions, which are emergency admissions. If these
admissions go straight to a ward, they should not be counted as lodged
patients. If these admissions remain in the nursing care of the Accident
and Emergency (A&E) department, they are accommodated as lodged
patients from the time of arrival until a bed on a ward is available. Such
patients occupy space and require nursing attention, and information
about them is needed for assessing the quality of care and the workload
of staff in the A&E department.
1.1.3
Each patient attending an A&E department will have a casualty card.
The casualty card is a paper record of any treatments and procedures
undertaken by medical staff whist the patient is in the A&E department,
it
also
contains
the
patients
demographic
details and
discharge/admission details.
1.2
Purpose
1.2.1
The purpose of this procedure is to give detailed instructions on how to
process patients who come into the Accident & Emergency Department
on the Patient Administration System (PAS).
1.2.2
The purpose of this procedure is to give detailed instructions on how to
ensure that the Trust’s Emergency care information is accurate, up-todate and complete. This procedure document also provides detailed
instructions on how to process the patient on the PAS within the A&E
function of the PAS.
1.2.3
This procedure is written to provide staff guidance when using the
Inpatient function of the PAS. Staff should also refer to the PAS
Training Manuals for:







Master Patient Index
Case-note Tracking
Discharges and Transfers
Admissions for Inpatients
PAS Codes and Key Strokes Booklet
Outpatient Booking
A&E
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2
General Procedure
2.1
2.1.1
Unknown Patients
For patients where the date of birth is not known, a universal temporary
date of birth must be entered – 08/08/1888. A temporary case-note
number will be automatically created.
The temporary case-note number is a seven digit number i.e. 0000001,
0000002 etc.
Note: If the universal temporary date of birth is entered, further
information about the patient must be entered as soon as possible, in
particular the patient’s correct date of birth must be entered.
Note: Every effort should be made to identify the patient by checking
belongings, checking with police if they accompanied the patient etc.
before the patient is registered.
2.1.2
As soon as the patient’s details are known, the PAS must be updated
with the correct details. A search for the patient must be undertaken.
Even when it is thought the patient has been found the search must
continue to check for duplicates and then pick up the right case note
number.
2.1.3
If the patient is found to already be on the PAS this will mean a
duplicate record has been produced, medical records must be informed
that there is a duplicate registration on the PAS (Appendix 1).
2.2
Patients brought in by Ambulance
2.2.1
Details of patients who arrive by ambulance are contained within the
‘Ambulance Sheet’ this will have been completed by the ambulance
crew and must be passed to the A&E reception staff.
2.2.2
The patient is booked in as per the instructions starting at section 2.4
Locating a Patient on the PAS using the information from the
‘Ambulance Sheet’ and any additional information from the Ambulance
Personnel.
2.2.3
When a patient arrives by ambulance and is taken straight into the ASU
(Ambulatory Specialty Unit), a front sheet must be produced by
reception staff and passed to the ASU to attach to the casualty card.
Note: Any discrepancies/missing data must be confirmed with the
patient or relative at the earliest opportunity.
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2.3
See and Treat
2.3.1
Once a patient has been booked onto the PAS, the trust operates a
new system. Each patient will be seen by a senior nurse in the A&E
reception area to assess the patient’s condition.
2.3.2
When the senior nurse has assessed the patient’s condition, the nurse
will direct the patient to the most appropriate area for treatment.
2.3.3
Resuscitation patients or children are treated immediately and do not
need to be assessed by the senior nurse.
2.4
Locating a patient on the PAS
Enter Unit No, name, ‘=’ for current – at this prompt enter the
patient’s case-note number, or search for the patient.
2.4.1
To locate a patient on the PAS, the following steps must be followed:
2.4.2
First Attempt: enter the patient’s case-note number if known, press
return.
2.4.3
Second Attempt: enter the patient’s Surname, followed by a comma,
followed by only the first 3 letters of the first name, press return.
Example:
2.4.4
smith,alb
(Searching for Smith, Albert)
Third Attempt: if the patient has not been found on the first search,
search again using the patient’s date of birth only, press return.
Example:
&12011965 (Searching for patients born 12/01/1965)
Note: The PAS will search two years either side of this date, retaining
the same day and month. Patients with exactly the same date of birth
as that entered will be displayed first (highlighted), followed by those
either side of the year (starting with the earliest first).
Note: In general, do not be too specific with the search criteria, as
this will potentially exclude patients from the selection list.
Note: The main reasons for duplicate patient records on the PAS are:





When Crawley and East Surrey PAS were merged
Poor searches for the patient on the PAS
Patient has got married/divorced
Patient has two names i.e. Joseph James and uses second
name
New born baby registrations, where the child could be on the
PAS under either mothers or fathers surname
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2.4.5
All staff must ensure that they DO NOT add a patient unless it is
absolutely certain that the patient is not already on the PAS.
Note: In most cases, it is very likely that the patient will have been
treated at the Trust previously, so will have a record on the PAS.
2.5
Overseas Patient
2.5.1
Overseas Patient - Any person who has not resided in this country for
a continuous twelve months.
2.5.2
All patients must be asked, where possible, when they present
themselves at the Trust, if they have resided in this country for longer
than 12 months.
2.5.3
Any overseas patients must be clearly identified, this is done by placing
an ‘Overseas patient sticker’ in the top right corner of the casualty
card.
Overseas patient stickers are available from the Income
Recovery Manager.
2.5.4
Emergency care is free to all people, regardless of where they live. If
an overseas patient is seen in A&E, the front of the casualty card must
be photocopied and sent to the Income Manager, Maple House, East
Surrey Hospital.
2.5.5
If a decision to admit an overseas patient is made, within working hours
(9am - 5pm Monday - Friday) the Income Recover Manager must be
contacted on extension 1702.
2.5.6
If no-one answers the telephone or it is outside of office hours, a
message must be left on the answerphone, stating the ward the patient
is being admitted and the patient’s case-note number.
2.5.7
The Income Recovery Manager will inform the overseas patient that
they could be charged for their treatment.
2.6
Multiple/Duplicate/Old Prefix records on the PAS
2.6.1
If when searching the Master Patient Index (MPI) for a patient and the
PAS displays either a:
2.6.2
Multiple Patient Record - more than one case-note with different
prefix’s i.e. A, B, E, K, S, F, X, new trust number.
Note: In these circumstances record the attendance against the record
that is located in the same area as the patients’ address.
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2.6.3
Duplicate Record - more than one record for a patient on the PAS
system are identified.
Note: In these circumstances record the attendance against the record
with the most recent activity.
2.6.4
Old Case-note prefix number - these are case-notes that are prefixed
by K, S, F or X on the PAS.
Note: These numbers are only to be selected if there are no other
records on the PAS.
2.6.5
A patient is identified as having duplicate records, multiple entries or a
record with an old prefix, either when the patient search was
undertaken or, if the patient was registered as ‘Unknown’ and later
found to have attended the Trust on a previous date.
2.6.6
To highlight this to Medical Records a front sheet for each of the entries
must be printed off and attached together with a covering memo
(Appendix 1) and then sent to the Medical Records Manager at the
appropriate site.
2.7
Updating Patient Details on the PAS
2.7.1
Staff must ensure that they update patient details on the PAS as soon
as possible.
2.7.2
This will ensure that the PAS contains the most up to date information.
2.7.3
Therefore, when checking case-notes against the PAS, staff would take
the information that is on the PAS as the correct information, and
should check with the patient before changing any details on the PAS.
Example: Patient has been sent an Outpatient appointment letter to
their old address, the patient has telephoned the Trust to inform them of
a change of address, but the old address is still detailed in the casenotes.
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3
Booking in Patients
3.1
3.1.1
Patient Type
Each patient that arrives at the A&E department will fall into one of the
following categories:




Review Appointment – section 3.2 Booking in Review Patients
Minor Operation Appointment - section 3.3 Booking in Minor
Operations
Patient sent by their GP –section 3.4 Booking in Lodged
Patients
Patient with a new complaint - this can be broken down into:
1. 3.5 Booking in New Attendances (patients that have not
previously attended the Trust.
2. 3.6 Booking in New Attendances(patients that have
previously attended the Trust).
3.2
3.2.1
Booking in Review Patients
Definition: Review Appointment – When a patient is treated in A&E,
the patient may be asked to return at a later date, so the treatment they
received can be monitored.
Note: A review appointment will either be booked or the patient is
asked to attend A&E at a later date (e.g. to return in a couple of days)
for follow up treatment.
3.2.2
A patient can turn up for their treatment to be reviewed at a different
A&E department from the one they were originally treated at. When this
happens the patient must be booked in as a new appointment. The
PAS does not allow the patient details to be updated or corrected.
3.2.3
If any of the patient details need to be updated/corrected the A&E
receptionist must complete to ‘Update Patient Details’ form (Appendix
2) and send the form to the A&E department that originally treated the
patient.
3.2.4
For all booked review appointments, the patient’s casualty cards should
be pulled the day before the appointment using the appointment list
sheet.
3.2.5
Once the casualty cards have been pulled they should be placed ready
for the patient’s appointment.
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3.2.6
When the patient arrives at A&E they may have an appointment card,
the patient must be asked the following details:
 Name
 Date of Birth
3.2.7
Once the patient’s details have been provided either collect or pull the
patient’s casualty card.
3.2.8
Using the details on the casualty card confirm with the patient their
details (e.g. name, address, date of birth etc) to ensure the correct card
has been selected.
Note: The reception staff must ask the patient for their details rather
than asking them to confirm the details on the casualty card.
Select menu ‘A&E Follow Up Attendance’, press return.
The PAS will display a message ‘Enter A&E number or ’M’ for MPI
search’. If the patient’s A&E number is known, type it in, press return.
If the patient’s A&E number is not known, type ‘M’, press return.
Locate the patient on the PAS; using the search criteria outlined in
section 2.4 Locating Patients on the PAS System.
3.2.9
Once the patient’s details have been found on the PAS any A&E
attendances for this patient will be listed. Select the last A&E
attendance that matches the casualty card and record the new
attendance as follows:
Screen 1





Arrival Date – enter the date the patient arrived at the hospital,
press return.
Arrival Time – enter the time the patient arrived at the hospital,
press return.
Planned Visit – type ‘Y’, press return. This is always completed
‘Yes’ as the patient has a pre-booked appointment
Triage Priority – type ‘-‘ to display the drop down list, select,
‘Review Clinic’, press return.
New Patient location – type ‘-‘ to display the drop down list,
select, ‘Waiting Room’, press return
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
3.2.10 AS will display a message ‘Print Labels (L) A&E Sheet (S) Both (B)
or None (N)’, type ‘S’, press return to print a front sheet for the casualty
card.
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3.2.11 A new front sheet will be produced (White for Adults, Yellow for
Children) and attached to the previous casualty card.
3.2.12 The casualty card is then passed to the Review Clinic Nurse along with
any x-rays.
3.2.13 At Horsham, the front of the casualty card is stamped with the Follow up
stamp. The time the patient arrived is written in the appropriate box.
3.3
Booking in Minor Operations (Crawley)
3.3.1
A list of arranged appointments for minor operations is supplied to the
A&E reception on the day of the clinic along with the case-notes for
these patients. Case-notes for these patients are pulled by Medical
Records Department.
3.3.2
When patients arrive at A&E reception, they must be manually marked
on the appointment list and the case-notes for the patient should be
passed to the Minor Operations Nurse.
Note: A label from the patient’s case-notes should be placed on the
minor operations checklist.
Note: East Surrey do not run Minor Operations, any minor operations
are dealt with by the Appointments Office and seen at the DTC
(Diagnostic Treatment Centre). Horsham do not run Minor Operations,
any minor operations are dealt with as a Review Appointment under Mr
Mabrook’s clinic.
3.4
Booking in Lodged Patients (East Surrey & Crawley)
3.4.1
Lodged patients – These are patients that have been to their GP. The
GP will have contacted the hospital and arranged for the patient to be
seen as an emergency by a specialty. The GP should write a letter
referring the patient to the relevant specialty. The patients then arrive at
hospital via the A&E department.
3.4.2
The ‘white board’ within the A&E Department should have a list of the
patients that are expected by the various specialties, this can be
checked when a patient arrives and does not have a referral letter from
their GP.
3.4.3
All lodged patients that have attended the Trust before must have their
case-notes requested from the Medical Records Department.
Note: If the patient’s set of case-notes are not available (e.g. at the off
site storage) and case-notes are required, a ‘Temporary Set’ must be
made up see section 6.5 Temporary Case-notes.
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3.4.4
If the patient was not located on the PAS, go to section 3.5 Booking in
New Attendances (that have not previously attended the Trust).
3.4.5
If the patient was located on the PAS, go to section 3.6 Booking in New
Attendances (that have previously attended the trust).
3.4.6
The nursing staff must inform the relevant specialty that the patient has
arrived in A&E.
3.5
Booking in New Attendances
(that have not previously attended the Trust)
3.5.1
If the patient is not on the PAS, the patient must be registered on the
PAS, the following details must be recorded:
Screen 1









Surname
Christian name
Title
Sex
Birth Date
Registered GP - If the indicated GP is not on the PAS enter
‘9995’ (Unknown GP Code) and complete the ‘Application for
Additional GP on the PAS’ (Appendix 3).
Ethnic Category – Whenever possible staff should ask the
patient their Ethnic Category (Appendix 4) is designed to assist
staff explain to patient’s why the Trust requests this information.
If the question is not asked, ‘Not asked’ must be selected from
the drop down list.
Marital Status
Patients Usual Address – This must be recorded, although on
rare occasions can be recorded as ‘Unknown’.
Note: If the patient does not reside in Great Britain the home country
address needs to be obtained and recorded as an Overseas Visitor,
see section 2.5 Overseas Patients.



3.5.2
Telephone number(s)/ Mobile Telephone Number
Next of Kin details
MPI Comment – this is always ‘AE’
Now proceed to section 3.8 Recording Patients Attendance.
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3.6
3.6.1
Booking in New Attendances (that have previously
attended the trust)
After the correct patient has been identified on the PAS, the following
information must be double checked with the patient:
Note: The reception staff must ask the patient for the above details
rather than asking them to confirm the details.
Screen 1
 The Registered GP
 Address - If the address has changed ensure that the address
history is saved
 Phone number(s)
 Next of Kin details – name and address
3.6.2
Once these patient’s details have been entered, a list of previous
attendances will appear on the screen. If the patient has listed a recent
A&E attendance (within the last 40 days) for a complaint that the patient
feels is connected, go to section 3.7 Booking in A&E Unplanned Follow
Up Attendance.
Note: Refer to the Accident & Emergency Policy for a full description of
first and follow-up attendances.
3.6.3
If the patient’s attendance was over 40 days ago, the patient needs to
be treated as a new attendance, for all new attendances proceed to
section 3.8 Recording Patients Attendance.
3.7
Booking in A&E Unplanned Follow Up Attendance
3.7.1
Select menu ‘A&E Follow Up Attendance’, press return.
3.7.2
Enter the patient’s case-note number, press return.
3.7.3
Once the patient’s details have been found any attendances for this
patient will be listed on the screen. Select the A&E attendance relating
to the complaint and then pull the corresponding casualty card.
3.7.4
The following details must be recorded on the PAS system:
 Arrival Date – enter the date the patient arrived at the hospital,
press return
 Arrival Time – enter the time the patient arrived at the hospital,
press return. Patients brought in by ambulance the arrival time is
when the patient was seen by the senior nurse or 15 minutes
after the ambulance arrives at A&E, whichever is earlier.
 Planned Visit – type ‘N’, press return. This is always completed
‘No’ as the visit was not planned.
 Triage Priority – type ‘-‘ to display the drop down list, select
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
‘standard’, press return
New Patient location – type ‘-‘ to display the drop down list,
select, ‘Waiting Room’, press return
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
3.7.5
PAS will display a message ‘Print Labels (L) A&E Sheet (S) Both (B)
or None (N)’, type ‘S’, press return to print a front sheet for the casualty
card.
3.7.6
Once these details have been entered a new front sheet will be printed
(White for Adults, Yellow for Children).
3.7.7
The patient’s previous casualty card must be pulled from filing and the
new front sheet attached to the previous casualty card, the casualty
card is then passed to the Triage Nurse.
3.7.8
Where applicable casualty cards for children are forwarded to the
Paediatric Triage Nurse; a call is always put out for the Paediatric
Triage Nurse to alert them of the child’s presence.
3.8
Recording Patients Attendance
3.8.1
Once a patient’s demographic details have been recorded/updated, the
patient’s attendance must be recorded.
3.8.2
The following data items must be collected from all patients attending
A&E:
Screen 2
 Arrival Time – enter the time the patient arrived at the hospital,
press return. Patients brought in by ambulance the arrival time is
when the patient was seen by the senior nurse or 15 minutes
after the ambulance arrives at A&E, whichever is earlier.
 Incident date & time – record this information, if provided by the
patient
 Presenting Complaint – if the patient is a lodged patient, within
this field type ‘Lodged for and the Speciality type’ i.e. Medics,
Orthopaedics etc
 Incident Type – if Road Traffic Accident (RTA) is selected,
additional information must be entered on the PAS is required, go
to section 3.9 Road Traffic Accident (RTA).
 Place of Incident
 Mode of Arrival
 Accompanied By
 Referral Source – For patients with a referral letter from their
GP, select one of the GP lodged options e.g. ‘GPCOE –
LODGED PAT FOR COE’.
Where it is unclear if the patient has been accepted for treatment
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

by the specialty team, choose the option ‘GP-GP’
Employer/School - this field must be completed when dealing
with either children of school age or if the incident occurred in the
wok place.
Temporary local address – complete is applicable.
Screen 3
 Referring GP
 Religion
 Next Of Kin Informed – Ensure that is it recorded on the PAS
whether the Next of Kin has been informed of the patients visit to
A&E
 Relation – the patient’s relationship to next of kin
 Emergency Contact
 Address and telephone number of emergency contact
3.8.3
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
3.8.4
PAS will display a message ‘Print Labels (L) A&E Sheet (S) Both (B)
or None (N)’, type ‘S’, press return to print a front sheet for the casualty
card.
3.8.5
Once these details have been entered a new front sheet will be
produced (White for Adults, Yellow for Children).
3.8.6
The casualty card must be passed to the Triage Nurse.
3.8.7
Where applicable casualty cards for children are forwarded to the
Paediatric Triage Nurse; a call is always put out for the Paediatric
Triage Nurse to alert them of the child’s presence.
3.9
Road Traffic Accident (RTA)
3.9.1
It is essential that the following information for a Road Traffic Accident
(RTA) is collected correctly, as the Trust receives income from patients
treated as a result of an RTA, who make a claim for compensation. If
the following information is not collected, then the Trust will be unable to
verify the patient’s treatment information required and this will result in
loss of income to the Trust.
3.9.2
The ‘Income Recovery Manager’ will use the following information to
verify the patient’s attendance and treatment to ensure the full costs are
recovered.
3.9.3
The following information must be recorded from all patients attending
A&E that have been involved in a Road Traffic Incident:
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Screen 4






RTA Category
Seat Belt Worn?
Accident Location
Treated at scene
Insurance
Car Registration No.
3.10
Disposing of Casualty Cards
Note: A disposal cannot be completed unless the disposal section on
the FRONT OF THE CASUALTY CARD has been filled in, if this is not
the case the casualty card should be returned to the Nurse in charge for
action.
3.10.1 The casualty cards are disposed once a patient leaves the A&E
department. When a patient leaves A&E the patient has either:




been admitted to a ward
transferred to another hospital
sent home
left before being treated.
3.10.2 Disposing the casualty records the details of the patients visit and the
patients outcome on the PAS. It also ensures only patients who are
currently in the A&E department are active on the PAS.
3.10.3 Casualty Cards for patients who have left the A&E department will be
collected on a regular basis from any appropriate locations.
3.10.4 If the casualty card has been marked (this is usually on the front) that
an outpatient appointment is required for the patient this information
must be recorded under Screen 6 ‘Follow Up Care’ (see below). Once
the casualty card has been disposed on the PAS, the outpatient
appointment must be booked, section 5.1 Dealing with Referral
Requests.
3.10.5 The following data will be taken from the casualty card and entered into
the PAS:
Screen 1
 Treatment Date – enter the date the patient was first seen by a
treating clinician
 Treatment Time – enter the time the patient was first seen by a
treating clinician
 Patient Group - this is taken from the back of the casualty card
under the ‘patient group’ section
 Allergies – this is taken from the first page of the casualty card
under the ‘history’ section, the Triage Nurse will have recorded this
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on the casualty card. only complete this field when instructed by a
Healthcare professional.
 Special Case Notes – Not applicable
 Special Case Free Text - Not applicable
 Local Interest Factors – select from drop down list if applicable
Screen 2
 Request Date - unless an investigation is dated, leave blank
 Request Time - unless an investigation is timed, leave blank
 Requested By – this is the unique identification code of the
treating clinician that saw the patient and must be entered
Appendix 5 provides a list of Doctors Names and Identification
Codes
 Investigation – this is taken from the back of the casualty card
under the ‘Investigations’ section
 Comments – Not applicable
Screen 3
 Code – this is taken from the back of the casualty card under the
‘General Diagnosis’ section
 Description – this is taken from the back of the casualty card
under the ‘Anatomical Site’ section
Screen 4
 Request Date - unless a treatment is dated then leave blank
 Request Time - unless a treatment is timed then leave blank
 Requested By – this is the unique identification code of the
treating clinician that saw the patient and must be entered
Appendix 5 provides a list of Doctors Names and Identification
Codes
 Treatment – this is taken from the back of the casualty card under
the ‘Treatment’ section
 Comments – Not applicable
Screen 5
 Record a new equipment loan (Y/N) {N} – N is normally recorded
Screen 6
 Disposal Type – this is taken from the front sheet of the casualty
card under the ‘Disposal’ section
 Disposal Date – this is taken from the front sheet of the casualty
card under the ‘Disposal’ section
 Time – this is taken from the front sheet of the casualty card under
the ‘Disposal’ section
 Follow Up Care – select the correct follow-up care from the drop
down list
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 Remarks – this is a free text option and would normally be used to
record things e.g. To record the Ward the patient has gone to or to
record the Clinic Appointment details
 Discharged By - this is the unique identification code of the
treating clinician that has seen the patient and must be entered.
Appendix 5 provides a list of Doctors Names and Identification
Codes.
 Free Text Diagnosis – this is a free text option not normally used
Note: Disposal must be when the patient physically left the A&E
department therefore referrals to specialties or to other hospitals are not
disposals and should not be used.
3.10.6 On the last page of disposing pick up (1) GP – ESH A&E Attendance
Letter and type “N” to produce letter from PAS.
3.11
Casualty Cards Administration
3.11.1 Before filing any casualty cards the following action must be carried out
where appropriate:
 All casualty cards for children must be photocopied and the copy
placed into the ‘child welfare tray’ once this has been done a cross
must be marked on the bottom right hand corner of the original
casualty card to indicate that the card has been copied
 Any patients presenting with DSH (Deliberate self harm) or
psychiatric problems must have their casualty cards
photocopied and the copy along with any paper work from the
Psychiatric team placed into the ‘Psychiatric Liaison Nurse pigeon
hole’ once this has been done a cross must be marked on the
bottom right hand corner of the original casualty card to indicate
that the card has been copied
 All casualty cards that have been marked by the ENP (Emergency
Nurse Practitioner) patient to return, must be placed in the
appropriate filing
 Any casualty cards returned to reception with paperwork that has
been produced by a specialty team must have their casualty card
photocopied and the specialty teams paperwork attached to the
copy.

The paper work will be checked to see if the patient requires any
follow-up appointments. If this is the case the paperwork along
with the copy casualty card must be sent to the Specialty
Consultant’s Secretary. If there is no follow the copy casualty
card is placed in the patient’s case notes.

If this is not the case the details of the patient will be added onto
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the ‘Non Urgent Case-note to be called for’ list’ (Appendix 6) this
list will be faxed to the relevant medical records department as
soon as there are a few entries on this list.
 All casualty cards that have been marked (this is usually on the
front) that an outpatient appointment is required must be checked
on the PAS to ensure that this has been done before the casualty
card is filed, see section 5.4 Dealing with Referral Requests.
3.12
Filing Casualty Cards
3.12.1 Children’s (up to 16 years old) casualty cards are filed separately to the
adult’s casualty cards, in alphabetical order, on the patients surname
and then first name, within the designated filling cabinets.
Note: For filing casualty cards, a child is up to the age of 16.
3.12.2 Adult’s casualty cards are firstly filed within the section for the day of
attendance and then alphabetically on the patients surname and then
first name within that section.
Note: If when filling a casualty card another card is present for the
same patient, the new card must be attached to the old card.
3.13
Medical Assessment Unit (MAU)
3.13.1 The purpose of the unit is to ensure the effective and speedy initial
assessment, by a multi disciplinary team of medicine, and care of
elderly patients, who are referred to the hospital or self refer as
emergencies.
3.13.2 GP referrals
Patients who are referred to the hospital as an emergency by their GP
will go direct to the MAU.
3.13.3 Referrals from A&E
Patient who come to A&E and are then referred to the medical or care
of the elderly team will be transferred from A&E to MAU.
3.13.4 Referrals from Outpatient Clinics
The consultant who has seen the patient contacts the medical registrar
to arrange the patient’s transfer to MAU.
3.13.5 Once in the MAU, the patients will be assessed and a decision made
either to admit to a medical or care of the elderly ward, or to discharge.
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4
4.1
Admitting Patients
Admitting a Patient to A&E Department
4.1.1
When admitting a patient, all mandatory fields cannot be bypassed on
the PAS.
4.1.2
Once the Decision to Admit (DTA) or Decision to Observe (DTO) has
been made for a patient, the patient must be admitted to the A&E
Department on the PAS.
Note: An admission should not be recorded with a DTA. If a patient is
referred to CAU (Children’s Assessment Unit) or MAU (Medical
Assessment Unit), then they should not be admitted at A&E unless a
DTA has been made.
4.1.3
A blue/green ‘uncoded episode’ sticker must be stuck on the front of
the case-notes. This indicates that there is an uncoded episode for that
patient.
4.1.4
When this decision has been made, staff must request the patient’s
case-notes from Medical Records.
Select menu ‘Admissions Function‘, press return.
Select menu ‘Admission’, press return.
Screen 1
Enter the patient name or case-note number.
Screen 2
Select ‘IPG – Inpatient/Day Case admissions’, press return.
Screen 3
Patient’s demographic details – these are to be checked and a
mental note made of the area the patient lives in, for use further on.
Note: Ethnic category must be entered if known, if not known select
‘Not Asked’.
Screen 4
Bypass this screen.
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Screen 5
Bypass this screen.
Screen 6
Admitting Cons/GP – this is the code of the specialty consultant under
whose care the admission is being made. This will be established by
seeing which doctor was on call for the speciality the patient has been
admitted under. Type ‘-‘ to display a drop down list, select the correct
consultant, press return.
Referring GP – type ‘=’ to pull through the patient’s GP, press return.
Current Consultant – press return to bring the consultant through.
Speciality – type ‘-‘ to display a drop down list, select the correct
speciality, press return.
Admitting Diagnosis - type ‘-unk’ for unknown, press return.
Pat/Admin category – type ‘-‘ to display a drop down list, select the
correct patient category, press return.
Screen 7
Visit Type – type ‘-‘ to display a drop down list, select Inpatient/Daycase, press return.
Admission Type – this is always ‘AE’, press return.
Admission Source – always ‘UR’ (Usual residence), press return.
Int Mgt – type ‘-‘ to display a drop down list, select ‘Inpatient’, press
return.
Screen 8
Bypass this screen.
Note: For new patients/patient with no case-notes, PAS will ask for a
base location for the patients case-notes, this is based on where the
patient lives, see section 6.4.7.
For new patients, case-notes should be made up, see section 6.4
Making up Case-notes for New Patients. Current patients will have their
case-notes requested/retrieved from Medical Records if they have not
already been requested.
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Screen 9
This screen shows where the case notes are to be based.
Screen 10
Ward – Enter the ward that the patient has been admitted to e.g. A&E.
Room – type ‘-‘, then press ‘F7’ and select a bed i.e. ‘RDY’ indicates an
empty bed.
Note: If the screen displays a full stop, this means that the ward does
not have any available beds. Check the bed status for the ward.
A list of available beds will be displayed, select a bed that is displaying
‘RDY’.
PAS will display the following warning messages, ignore the warning
messages.
Warning: The patient’s sex does NOT match that of expected room
attendants!
Warning: Patient’s expected service specialty does NOT match bed
specialty!
‘Continue with selected bed ####, Y/N’, type ‘Yes’ or ‘No’ as
appropriate.
Accommodation –select ‘NHS’.
Admission Date – enter the date the patient was admitted.
Admission time – enter the time the patient was admitted.
Note: Ensure the actual admission date and time are recorded, not the
date and time the admission has been made on the PAS.
Initials – PAS will automatically enter your initials.
Screen 11
A list of beds/bays within the selected ward are displayed.
Search the list for a bed marked ‘RDY’ and select a bed.
At the end of the screen, a message will be displayed: No Estimated
Length of Stay (ELOS) specified, reserve bed for how many days –
type, ‘0’, press return.
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The PAS will display a warning, bypass these messages they are not
relevant.
PAS will display a message ‘Continue selected bed?’ –type ‘Y’ for
Yes, press return.
Enter off-service authorisation reason/person – enter your initials.
Screen 12
Admission Date – this is the decision to admit date on the
‘Admissions via A&E Sheet’.
Admission Time - this is the decision to admit time on the
‘Admissions via A&E Sheet’.
Note: Once this has been completed, mark the ‘Admissions to A&E
Sheet’ to show that the patient has been admitted on the PAS.
4.1.5
The admitted patients do not stay in the A&E department so one of the
following will occur:
 It will be decided that the patient needs to stay in the hospital, so
the patient will be transferred to a ward, section 4.2 Transferring
Patient to Ward within the Trust.
 It will be decided that the patient is well enough to go home,
section 4.3 Discharging patient from the A&E Department.
4.1.6
The casualty card must be photocopied and placed in the patients casenotes with any other care programme documents.
4.1.7
If the patient is then discharged home, the case-notes must be sent to
the A&E consultant’s secretary for the discharge summary to be typed.
4.1.8
At East Surrey, the case-notes must be forwarded to Medical records
for filing. At Crawley& Horsham, the Clinical Coding Assistant will
collect the case-notes.
4.1.9
If the patient is transferred to a ward, the case-notes must be tracked to
the ward. Before this is done, A&E staff must ensure that all
appropriate paperwork is filed correctly in the case-notes.
4.1.10 At regular intervals the reception staff will collect a copy of the
‘Admissions via A&E Sheet’ from the nurses station, the sheet
contains patients admission details and times and record the
information on the PAS.
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4.2
Harrowlands
Consultant
Dorking
GP/Intermediate
Caterham
GP/Intermediate
Caterham
Consultant
Horsham
Horsham
GP/Intermediate
CARE TYPE
Consultant
SITE
Consultant
SITE
Crawley
Transferring Between PCT (GP/Intermediate Care) and
Hospital (Consultant) Beds from Surrey and Sussex Trust
East Surrey : Consultant beds only
Crawley
: Consultant beds only
Horsham
: Consultant and GP/Intermediate Care beds
Caterham
: Consultant and GP/Intermediate Care beds
Harrowlands : Consultant beds only
Dorking
: GP/Intermediate Care beds only
East Surrey
Guide:
From 1st April 2003 some of the beds at Caterham Dene, Dorking and
Horsham Hospital transferred to Primary Care Trusts. Whilst all
Dorking beds are owned by EEMS PCT, Caterham and Horsham have
some PCT beds and some Trust beds. Please check with nursing staff
if you are unsure whether the patient is going to the care of a consultant
or care of a GP/Intermediate Care Team. The table below may be used
as a guide.
Consultant
4.2.1
Transferring Patient to Ward within the Trust
East Surrey
Consultant
Transfer
Transfer
Transfer
Discharge
Transfer
Discharge
Discharge
Transfer
Crawley
Consultant
Transfer
Transfer
Transfer
Discharge
Transfer
Discharge
Discharge
Transfer
Horsham
Consultant
Horsham
GP/Intermediate
Caterham
Consultant
Caterham
Dorking
Harrowlands
Consultant
Transfer
Transfer
Transfer
Discharge
Transfer
Discharge
Discharge
Transfer
Discharge
Discharge
Discharge
Transfer
Discharge
Discharge
Discharge
Discharge
Transfer
Transfer
Transfer
Discharge
Transfer
Discharge
Discharge
Transfer
GP/Intermediate
Discharge
Discharge
Discharge
Discharge
Discharge
Transfer
Discharge
Discharge
GP/Intermediate
Discharge
Discharge
Discharge
Discharge
Discharge
Discharge
Transfer
Discharge
Transfer
Transfer
Transfer
Discharge
Transfer
Discharge
Discharge
Transfer
4.2.2 If the ‘Admission via A&E Sheet’ indicates that the patient has been
transferred to a ward, the patient must be transferred on the PAS. If the
patient has been discharged from another site, the receiving hospital
must admit the patient on the PAS.
4.2.3 A patient must have been admitted to the A&E department before being
transferred to a ward. If the patient has not been admitted to the A&E
department, it is the responsibility of the ward clerk to contact the A&E
department requesting that they admit the patient as soon as possible.
4.2.4 The case-notes must be kept with the patient and tracked on the PAS to
the ward the patient is being transferred to, irrespective of which bed
they are going to.
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4.2.5
If the ward has admitted the patient directly, this admission must be
deleted with the reason ‘Admitted in Error’. The patient must then be
admitted to the A&E department and the transferred to the ward.
Select menu ‘Admission Function’, press return.
Select menu ‘Transfer’, press return.
Screen 1
Enter the patient name or case-note number.
Screen 2
Select the correct patient. The patient will be admitted to the casualty
ward. This will be highlighted by under the WRD Column ‘CAS’ is
displayed. Select this entry.
Note: If there is nothing displayed under the WRD column, this means
that the patient has not yet been admitted to the A&E Department. The
patient must be admitted to the A&E department before being
transferred to the ward, section 4.1 Admitting a Patient to A&E
Department.
Screen 3
Ensure the patient details are correct, in particular the patient’s name,
date of birth and Estimated Length Of Stay (ELOS) Discharge Date.
Enter the following information into the PAS:
Effective date – from ‘Admissions via A&E Sheet’ arrival to ward date.
Effective time – from ‘Admissions via A&E Sheet’ arrival to ward time.
New ward – ‘type ‘-‘ to display a drop down list, select the correct ward,
press return.
Room – ‘type ‘-‘ to display a drop down list, select the correct room,
press return.
Screen 4
A list of beds/bays within the selected ward are displayed.
Search the list for a bed marked ‘RDY’, select a bed, press return.
Note: If none of the beds/bays are marked ‘RDY’ contact the ward
requesting that they discharge a patient on the PAS.
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At the end of the screen, the PAS will display:
At the end of the screen, a message will be displayed: No Estimated
Length of Stay (ELOS) specified, reserve bed for how many days –
type, ‘0’, press return.
The PAS will display a warning, bypass these messages they are not
relevant.
PAS will display a message ‘Continue selected bed?’ –type ‘Y’ for
Yes, press return.
Enter off-service authorisation reason/person – enter your initials.
Screen 3 – continued (the PAS goes back to screen 3)
Accommodation – ‘type ‘-‘ to display a drop down list, select the NHS,
press return.
New service – press enter to bring through the consultants specialty.
Reason for Transfer – ‘type ‘-‘ to display a drop down list, select the
‘Transfer’, press return.
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
4.2.6
The patient has now been transferred to the ward. The Admission via
A&E sheet’ will now be marked to show that the entry has been
completed.
4.3
4.3.1
Discharging a patient from the A&E Department
This is completed for patients that have been admitted to the A&E
department and have then been discharged.
Select menu ‘Admissions’, press return.
Select menu ‘Discharge’, press return.
Screen 1
Enter the patients name or case-note number.
Screen 2
Select the correct patient. The patient will be admitted to the casualty
ward. This will be highlighted by under the WRD Column ‘CAS’ is
displayed. Select this entry.
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Note: If there is nothing displayed under the WRD column, this means
that the patient has not yet been admitted to the A&E Department. The
patient must be admitted to the A&E department before being
transferred to the ward, section 4.1 Admitting a Patient to A&E
Department.
Screen 3
Ensure the patient details are correct, in particular the patient’s name,
date of birth and Estimated Length Of Stay (ELOS) Discharge Date.
Enter the following information into the PAS:
Discharge Disposition – ‘type ‘-‘ to display a drop down list, select the
discharge disposition e.g. Medical Advice Usual Residence,
Self/Relative Usual Residence.
Reason/Comment – this is optional and can be used to extend the
above information.
Discharge Date – this is taken from the ‘Admission via A&E Sheet’.
Discharge Time - this is taken from the ‘Admission via A&E Sheet’.
If any of the above information is in not on the ‘Admission via A&E
Sheet’ then it could be obtained from the casualty card. If there are any
problems with discharging a patient consultant a supervisor/manager.
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
4.3.2
The patient has now been discharged. The ‘Admission via A&E
Sheet’ must be marked to show that the patient has been discharged.
4.4
4.4.1
Transferring Patient to another Trust
For this follow the instructions detailed in section 4.3 Discharging
patient from the A&E Department, but:
 Under Screen 3, field ‘Discharge Disposition’ select ‘Medical
advice Special Hospital’, press return.
 In the ‘Reason/Comment’ field, type the name of the Trust and
the ward (i.e. Queen Victoria – for burns) the patient has been
transferred to.
Note: Provide as much information as possible in the comment field, so
any member of staff can easily see where the patient has gone.
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5.1.1
5
Patient Referral Requests
5.1
Dealing with Referral Requests
Any requests for referral appointments for patients that have attended
Accident & Emergency must be dealt with in the following ways:
Note: These may be verbal requests or the request may be indicated
on the casualty card.

East Surrey Eye Clinic – this is a walk-in service and
appointments are not made in advance. Clinical staff will
produce a referral for the patient to take along to this Clinic.
Reception staff should photocopy the casualty card and place it
in the Eye Clinic pigeonhole.

Note: No entry is required on the PAS by the reception staff.

East Surrey Fracture Clinic – reception staff will receive verbal
fracture referrals. Staff must check the ‘Fracture Appointment
List’ (Appendix 7) to ascertain appointment availability and
select an appropriate appointment date and time. Once an
appointment is selected, staff must complete the ‘Fracture
Appointment List’ with the patients’ details and write the
appointment details on an appointment card and give this card to
the patient.
Note: If the patient lives in the vicinity of Crawley then an appointment for this
site would be required, and if the patient lives in the vicinity of East Surrey an
appointment would be required at this site.
5.1.2
To arrange an appointment for the other site, staff must contact the
relevant A&E department. This must be done while the patient is still
present.
5.1.3
If the patient has an appointment arranged for a different site that is less
than 3 days away, give the x-rays in the blue x-ray folder to the patient,
informing the patient, that they must take the x-rays to their
appointment.
5.1.4
Staff must complete an ‘X-ray tracking sheet’ and place it in the x-ray
box. All other x-rays must be placed in the x-ray box ready for
collection.
5.1.5
Review - when the reception staff receive a verbal review clinic request,
the ‘Review Clinic Appointment List’ (Appendix 8) to ascertain
appointment availability and select an appropriate appointment date
and time. Once an appointment selected, staff must complete the
‘Review Clinic Appointment List ’ with the patients’ details and write the
appointment details on an appointment card and give this card to the
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patient.
5.1.6
Any patients that have had an appointment booked for either the
‘Fracture Clinic’ or ‘Review Clinic’, the appointment must be booked
on the PAS, section 5.2 Booking Outpatient Appointments.
Note: Ensure that the patient is seen within the prevailing waiting
times.

All other specialties (e.g. ENT, Surgical, Urology, Medical,
Care of Elderly) Clinical staff must inform the patients who are
being referred to these Clinics that they will be contacted shortly
with an appointment. The reception staff must photocopy the
casualty card and forward it to the relevant Specialty Secretary
along with any paperwork. Once this has been sent, staff must
record on the front of the casualty card that this has been
completed.
Note: This must be done immediately so that the Secretary can ensure
that the patient is seen within the prevailing waiting time.
Note: If it has been identified that the patient requires transport, the
patient should be booked either a 10am slot or 2pm slot. An
‘Ambulance Booking Form’ should be completed and forward to the
Patient Transport department.
5.2
Booking Outpatient Appointments
Select menu ‘Outpatient Functions’, press return.
Select menu ‘Booking Appointments’, press return.
Screen 1
Search either under the consultant’s name (this will display any clinics
linked to the consultant) or resource number (this will display any clinics
under that resource).
Screen 2
Select the appropriate clinic e.g. For Fracture Clinic – Select EE,AFR,
For Review Clinic – EE1,CAS.
Screen 3
Enter the date and time of the patient’s appointment.
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
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Screen 4
Search for the patient, section 2.4 Locating a Patient on the PAS.
Screen 5
Select the correct patient.
Screen 6
The following demographic details must be checked to ensure that the
correct patient has been selected.
 Surname
 First Name
 Title
 NHS No
 Sex
 Date of Birth
 Ethnic Category
 Address
 Postcode
 Telephone Number/Mobile Telephone Number
 GP
Screen 7
Bypass this screen.
Is this a new visit – this is always ‘N’, press return.
Screen 8
A list of activity types will be displayed. Select ‘N’ to create a new
account, press return.
Screen 9
If there is a recent ‘OPR’ (Outpatient referral) entry for the same
consultant, this must be selected. If it is selected, the PAS will go to
Screen 14 and continue booking the outpatient appointment.
Screen 10
Admitting cons/GP – this will be the consultant that runs the clinic (this
will be on the appointment list).
Referring GP – type ‘=’ to bring GP through.
Current Consultant – press ‘enter’ will bring the consultant through.
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Specialty – type ‘-‘ to display a list of specialties, select the relevant
specialty.
Admitting Diagnosis – type ‘-UNK’, press return.
Pat / Admin Category – enter the patient type, this is normally ‘NHS’.
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
Screen 11
Visit Type – type ‘-‘ and select ‘Outpatient’, press return.
Referral date – date referred, this is taken from the appointment lists.
Referral Source – type ‘-‘ and select ‘A&E’.
Referral reason – type ‘-‘ and select ‘Advice and Consultation’.
Admission type – type ‘-‘ and select ‘routine’.
Admission Source – type ‘-‘ and select ‘N/A’ (Outpatients).
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
Screen 12
Bypass this screen.
5.2.1
Filling Location – this will only be displayed if no case-notes have
been created for the patient. If no case-notes have been created for the
patient ensure that the either: ‘Crawley No Notes’, ‘East Surrey No
Notes’ or ‘Horsham No Notes’ is entered into the comment field.
Screen 13
Bypass this screen.
Screen 14
On this screen, check the information to ensure that the appointment
date, time etc is correct.
Priority – type ‘-‘ and select ‘routine’
PAS will display a message ‘Accept this screen? Y/N’, type ‘Y’ or ‘N’,
press return as appropriate.
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5.2.2
The appointments list sheet must be marked to indicate that the
appointment has been made on the PAS.
5.2.3
For ‘Fracture Clinics’ the casualty card must be photocopied and placed
behind the appointments list sheet ready for Medical Records to collect.
The original casualty card is marked to show that this has been done.
5.2.4
Any X-rays must be placed in the Fracture Clinic box ready for
collection.
5.2.5
For ‘Review Clinics’ once the casualty card has been disposed. The
casualty card should be placed in the review clinic box along with any xrays.
5.3
End of day for review and Minor Ops
Select menu ‘Outpatient’, press return.
Select menu ‘End of day’, press return.
Screen 1
Enter clinic resource/consultants name or number, press return.
Screen 2
The PAS will display a list of clinics for that resource – select the
appropriate clinic.
Example: East Surrey - For review clinic – EE1 CAS, Minor ops – EE1
MUS.
Screen 3
Enter date of the clinic, press return.
Screen 4
The PAS will display all of the patients booked into the clinic – in time
order.
Select each patient in order and enter the outcome of the patient’s
appointment:
E - Edit
F – Fill
C – Cancel
N – No Show
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Once the outcome has been entered for one patient the PAS will move
to the next patient, enter the outcome for this patient. The same
process will continue until the each patient’s outcome has been
recorded.
A message will be displayed ‘Do you want to end, end of day’. Enter
either ‘Y’ for Yes or ‘N’ for no, press return.
5.3.1
The original appointment list will be marked to show that the end of day
process has been completed and then filed in appropriate area.
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6
6.1
Case-Notes
Tracking Case-notes
6.1.1
When a set of case-notes is made up for a patient, they must be
tracked in the Case-note Tracking Function on the PAS. Thereafter
whenever a set of case-note is moved, it must be tracked on the PAS.
6.1.2
The main benefit of the case-note Tracking System is that case-note
Borrowers and Locations are recorded efficiently and accurately
ensuring good patient care by the quick and easy location of casenotes.
6.1.3
The accuracy and success of this system depends entirely upon each
member of staff taking responsibility and ensuring that the case-notes
are tracked in ‘real time’.
6.1.4
Case-notes can be Batch Transferred; this is designed to allow the
selection and transfer of up to 15 case-notes or volumes to the same
borrower.
6.1.5
Every three months, the information department will provide a complete
list of borrowers to Medical Record Managers. Managers must check
this list to ensure that it is accurate and up to date.
6.1.6
The person passing the case-notes to another user is responsible for
recording this movement on the PAS. Therefore, the last recorded
borrower is responsible for any case-notes that are missing.
6.1.7
If a set of case-notes is removed and the recorded borrower is not
present, the person taking the case-notes is responsible for tracking the
case-notes, or completing a case-note tracking slip (Appendix 9).
6.1.8
Refer to the Case-note Tracking PAS Training Guide for full details on
how to track case-notes on the PAS and the Case-note Tracking Batch
Transfer PAS Training Guide for further information.
6.1.9
If the PAS is not available at the time a set of case-notes are taken from
a location, when PAS is available again, the person with the case-note
must ensure that the case-notes are tracked to the correct location on
the PAS.
6.2
6.2.1
Case-note numbering
The Trust uses a date of birth numbering system with a three-digit
suffix, which has been in effect from 1999.
Example:
Date of birth (DOB) 23rd June 1972 = 230672001 this
would apply to the first patient referred to the Trust with
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that date of birth.
Date of birth 17th October 1987 = 171087005 this would
apply to the fifth patient referred to the Trust with that
date of birth.
17
87
Month
of birth
Day of
birth
6.2.2
10
005
Year of
birth
Number of patients
registered on the PAS
with the same DOB
For patients where the date of birth is not known, a universal temporary
date of birth must be entered – 08/08/1888 and then a temporary casenote number will be automatically created.
The temporary case-note number is a seven digit number i.e. 0000001,
0000002 etc.
Note: If the universal temporary date of birth is entered, further
information about the patient must be entered as soon as possible, in
particular the patient’s correct date of birth must be entered.
6.2.3
Before 1999, the numbering system differed across the sites:



Crawley Notes
Horsham Notes
East Surrey Notes
A 31037401
B 31037405
E 31037412
Note: The East Surrey case-notes did not have the ‘E’ prefix written on
the case-note folders, but the letter is seen on the PAS.
A
Letter indicating
where case-notes
are held
31
Day of
birth
6.3
6.3.1
03
Month
of birth
74
Year of
birth
05
Number of patients
registered on the PAS
with the same DOB
Case-note structure
The order of filing within the case-note has been agreed by the Health
Records Committee and should not be altered without reference to the
Health Records Committee.
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6.3.2
The Trust approved format for new case-notes is blue for male patients
and pink for female patients, this must always be adhered to.
6.3.3
Case-note folders are issued from Medical Records with instructions on
the structure and use of the case-note folder as detailed below:
1st Spine
Correspondence
All letters of Referral/Treatment
All follow up correspondence
Discharge Summaries
Community Nurse Referrals
Correspondence must be hole-punched and filed in date order,
most recent LAST
2nd Spine
Patient Identification Sheet
Patient Labels
Pharmacy Card (Crawley/Horsham)
Orthopaedic Card (Crawley/Horsham)
Medical Notes
History Sheets
Diagnosis and Treatment Sheets
Integrated Care Pathways
Filed With Most Recent Notes last within The Speciality
Operation Notes
Consent to Treatment
Anaesthetic Records
Operation Records
Diagnostic Test
Pathology Reports
X-ray Reports
ECG Tracings
A separate Mount Sheet must be used for each of the following
sections:
BLACK – X-ray,
RED – Haematology,
BLUE – Biochemistry,
GREEN – Microbiology,
WHITE – Histopathology
Nursing Notes
All Nursing Care Plans
Intensive care Records
Fluid Balance Sheets
Medication Records
Prescription Cards
Patient Controlled Analgesia Records
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6.3.4
The medical notes comprise history sheets, diagnosis and treatment
sheets, which are colour edge-coded and integrated care pathways.










Yellow
Yellow and Blue stripes
Orange
Red
Blue
Purple
Black
Black and Yellow stripes
Green Card
Pink
6.4
6.4.1
Medicine
Oncology
Rheumatology
Ear, Nose and Throat
General Surgery
Neurology
Dermatology
Ophthalmology
Orthopaedic
Gynaecology
Making up Case-notes for new patients
A set of ‘Patient labels’ and a ‘Patient Identification Sheet’ must be
produced from the PAS:
Select menu ‘OP Function’, press return.
Select menu ‘Print function and other Instructions’, press return.
Select menu ‘Print form’, press return.
A message is displayed ‘Select Unit number, name’ - Enter the
patient’s case-note number or name.
On the next screen, a list of the patients live activity is displayed.
A message is displayed ‘Select account number’, pick up the current
patient episode, press return.
On the next screen, a list of forms and labels will be displayed.
PID – patient identification sheet
Labels – patient labels
Select the required number to print on a designated printer – the PAS
returns to the ‘Print Form’ menu, either exit or print other items.
Note: If the patient is not ‘active’ on the PAS, the PAS will not allow
either a front sheet or labels to be printed.
6.4.2
The PID and labels must be filed at the front of the second spine within
the case-note folder.
Note: Any ‘Patient labels’ remaining after making up the new case-note
are to be stored at the front of the second spine within the case-note
folder.
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6.4.3
A check should be carried out to ensure that all dividers are present
within the case-note and in the correct order.
6.4.4
When a patient attends the Trust for treatment, on the front of the casenotes, stickers are placed to indicate the year the patient attended for
treatment. At the beginning of every year the colour of the label will
change.
6.4.5
Year stickers have the year indicated on them along with the last two
digits of the year i.e.
01
2001
Note: It is important to ensure that every patient case-note that is used
for the patient’s treatment within the Trust has the correct year sticker
on the front.
6.4.6
Month stickers are colour coded; each month has it’s own colour and
reflect the month of the patients date of birth. These stickers are placed
around the edge of the case-notes. The month stickers are used to
highlight possible misfiling within the medical records library.












6.4.7
January
February
March
April
May
June
July
August
September
October
November
December
Red
Grey
Dark Green
Orange
Pink
Brown
Dark Blue
Black
Light Green
Light Blue
Yellow
Purple
When registering a new patient on the PAS, and a set of case-notes are
made up for the patient, the base location for the case-notes must be
decided. This is decided on the patients’ place of residence. The base
location will either be: Crawley (CR), East Surrey (ES), Horsham (HR).
East Surrey –
Crawley –
Horsham –
Caterham, Dorking, Horley,
Redhill and Reigate
Crawley
Horsham, Billingshurst
Accident & Emergency Procedure Version 3.0
Merstham,
Oxted,
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6.4.8
When registering a new patient, the PAS will display the following
prompt ‘Accept <site> as the site location for the chart? Y/N’.
Ensure that the correct location is selected.
6.4.9
When the case-notes are made up the base location of the case-notes
must be recorded in the ‘MPI Comment’ field’.
6.4.10 If at the time of registering the patient on the PAS and a set of casenotes are not made up, then this must be recorded in the ‘MPI
Comment’ field e.g. CR No notes, ES No notes, HR No notes. When a
set of case-notes are made up for a patient, the comment ‘No Notes’
must be removed and the case-note base location entered (see section
above).
6.4.11 The base location for the case-notes must be stamped on the front.
6.4.12 The diagrams overleaf show the correct labeling up of case-notes using
the patient labels, year label and month label.
Year
Label
Month
Label
Female (Pink)
Surname ______________
First name _____________
2002
02
This way up
PLEASE TRACER
THESE CASE-NOTES
SURREY AND SUSSEX HEALTHCARE NHS
TRUST
CONFIDENTIAL
NOT TO BE TAKEN OUT
OF THE HOSPITAL
ALERT !
Accident & Emergency Procedure Version 3.0
Surname
and casenote
number
Unit No ________________
Surname _______________
Complete
Name on
this side
This way up
First name _____________
Case-note
No
Patient Label
Spine of
Folder
Unit No ________________
Patient Label
Page 39 of 59
Unit No ________________
Spine of
Folder
First name _____________
PLEASE TRACER
THESE CASE-NOTES
SURREY AND SUSSEX HEALTHCARE NHS
TRUST
CONFIDENTIAL
NOT TO BE TAKEN OUT
OF THE HOSPITAL
ALERT !
6.5
Complete
Name on
this side
Unit No ________________
This way up
Month
Label
Patient Label
02
2002
Surname _______________
This way up
First name _____________
Surname
and casenote
number
Patient Label
Surname ______________
Male (Blue)
Casenote No
Year
Label
Temporary Case-notes
6.5.1
Definition: A temporary case-note is a set of case-notes that have
been created when the original set of case-notes has been declared
missing.
6.5.2
Temporary case-notes are contained within an Orange case-note
folder. The structure within the case-note must follow the standard
case-note format see section 6.3 Case-note Structure.
6.5.3
Only a Supervisor or a Manager can authorise the creation of a
Temporary set of case-notes.
6.5.4
The temporary case-note will contain as much information as possible –
copies of previous letters, any available results, patient identification
sheet and patient labels.
6.5.5
The patient identification sheet must be marked with the date and
reason for creating the temporary set of case-notes.
6.5.6
In the ‘MPI Comment’ field, it must be entered ‘Temp File’ and ‘Date
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created’.
6.5.7
Temporary case-note must be tracked, but it must be clearly identified
that it is the temporary set of case-notes that are being tracked.
6.5.8
Temporary case-notes must be filed within the main Medical Records
Library.
6.6
Transporting Case-notes
6.6.1
All case-notes must be transported in a safe and secure manner to
ensure patient confidentiality. Case-note trolleys should be used to
transport large numbers of case-notes to safeguard the Health and
Safety of staff.
6.6.2
At no time should either case-notes or trolleys of case-notes be left
unattended.
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7
Security and Confidentiality
7.1
Requests for Information
7.1.1
Requests for patient information either in person or by telephone is only
permitted in line with the Disclosure of Patient Information Policy.
7.1.2
Careful consideration should be given to all requests for patient
information.
7.1.3
The Data Protection Act 1998 and the Caldicott principles should be
applied to all requests for information.
7.1.4
All requests for information from individuals not employed by the Trust
must be supplied in writing using the Trust approved form (Appendix
10). Written requests must be handled by the designated officer on
each site or nominated deputy.



East Surrey - Chris Howe Ext 6740
Horsham – Vanessa Durnin Ext 3692
Crawley - Vanessa Durnin Ext 3692
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8
8.1
Deceased Patients
Patients that are Dead on Arrival to A&E
8.1.1
All patients that arrive at the Hospital deceased will be booked in, see
section 2.4 Locating a Patient on the PAS. The details of the patient
can be obtained from the person who accompanied the patient to the
A&E department.
8.1.2
Ensure that whilst recording the patient’s attendance, under screen 2 in
field ‘Presenting Complaint’, type ‘Dead On Arrival (DOA)’.
8.1.3
The Corner should be informed that a deceased patient has arrived in
A&E.
8.2
Patients who die in A & E
8.2.1
When a patient dies in A&E, the casualty card must be marked with the
patient’s date and time of death.
8.2.2
On the receipt of any death notification, the following actions need to
take place:
 The patient needs to be identified on the PAS
 The MPI function must be changed to reflect the fact that the
patient is deceased by completing the ‘DOD field’ with the date of
the patient’s death
Note: This action will set off an automatic cancellation of all
outstanding appointments and referrals
 If the case-notes are in the A&E department, the case-notes must
be retrieved and the front of the case-note must be stamped
‘deceased’ and the date of death noted under the stamp. The
case-notes must then be sent to the Medical Records manager to
ensure that the case-notes are dealt with in accordance with the
Medical Record procedure
8.2.3
The original casualty card must be placed in the Coroners box and if
appropriate a note made in the communications book to notify other
members of staff. The Coroners Office sights the original casualty card
and returns it to A&E.
8.2.4
Medical Records must be alerted to the death of the patient. This is
done printing off a front sheet and forwarding it to the Medical Records
library in the appropriate area.
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9
Contacts
Position
Name
Extension
Elin Williams
6903
Team Leader – East Surrey
Julie Reid
6934/6061
Team Leader – Crawley
Debbie Warner
3704
Outpatient/Medical Records Manager
Anita Gurcan
6732
Medical Records Manager (East Surrey)
Christine Fox
6723
Medical
Records
(Crawley/Horsham)
Janice Favier
3690
Outpatients Improvements Manager
Jane Andoe
6730
Waiting List/Admissions Manager
Jan Roberts
6223
CBO Supervisor
Debbie Trinder
2824
Data Quality Manager
Lyndee Peters
6520
Income Recovery Manager
Pam Ward
1702
PAS Manager
Mark Warman
1711
Assistant
General
Emergency Care
Manager
of
Manager
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10
Managers Procedures
10.1
Sample Checking
10.1.1 Sample checks will be undertaken on a regular basis.
10.1.2 The sample checking will consist entail:



Taking a 10% population of all A&E attendances
Checking the casualty cards non completeness
Checking the casualty card against the PAS for completeness
and accuracy.
10.1.3 Whilst undertaking sample checking all errors are corrected.
10.1.4 Daily sample checking sheets (Appendix 11) are filed in the A&E
department.
10.1.5 The A&E Team Leader together with the Data Quality Manager is
responsible for collating the daily results monthly.
10.1.6 The monthly sample checking collation report is distributed to:




Team Leader for A&E (Crawley and ESH)
Assistant General Manager for Emergency Care
Consultant for A&E
Data Quality Manager
10.2
Dealing with Data Quality Reports
10.2.1 Data Quality Reports are being designed in conjunction with the
department manager/A&E Team Leader.
10.3
Completeness Report
10.3.1 A report highlighting fields left incomplete on the PAS is forwarded from
the Data Quality Manager to the A&E Team Leaders on a monthly
basis.
10.3.2 The report summarises by percentage and details by case note,
patients who have attended A&E and where A&E staff have missed or
have been unable to collect information for the patient’s PAS record.
10.3.3 A&E staff will use this report to complete missing information where
possible and to monitor improvement in the collection and input of data
onto the PAS.
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10.4
Case Note Tracking
10.4.1 At the end of each week the A&E Team Leader, together with reception
staff, check all case-notes held at A&E reception.
10.4.2 Where patients have been discharged or have been transferred from
A&E to another area of the Trust, the tracking is updated on the PAS
and case-notes forwarded to the appropriate area by the end of the day.
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11
11.1
Appendices
Appendix 1 - Highlighting Possible Duplicates/Multiples/Old Prefix’s
Memo
MEMORANDUM
To:
Medical Records Manager
Subject: Duplicate Records/
Multiple Entries/
Old Prefix’s*
From:_________________________________
Date: _________________________________
* Please delete as appropriate
Please find attached copies of a front sheet for each record on the PAS for the same patient.
The patient’s episode of care has been recorded against the following case-note number:
____________________________________________________________________________
If the reason for the duplicate/multiple entry on the PAS is known, please provide the reason below
e.g. patient entered by mistake, patient came into A&E unconscious, therefore patient was given a
temporary number etc.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
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11.2
Appendix 2 – Patient Update Details Form
Surrey & Sussex Healthcare NHS Trust
MEMORANDUM
To:
Subject:
East Surrey A&E Reception*
From:
East Surrey A&E Reception*
Crawley A&E Reception*
Crawley A&E Reception*
Horsham Minor Injuries Unit*
Horsham Minor Injuries Unit*
*Please delete as appropriate
*Please delete as appropriate
Update Patient Details on the PAS
Date: ____________________________
Please can you update the following patient’s information on the Patient Administration System
(PAS).
Patient Name: _____________________________________________________________
Patient Case-note Number: __________________________________________________
Information that requires updating: ___________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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11.3
Appendix 3 - Application for Additional GP’s on the PAS
To: PAS Manager, Maple House, East Surrey Hospital
From:
_______________________________ A&E Department: ________________________
Date: _______________________________________________________________________
Please add the following GP to the PAS:
GP Name: ___________________________________________________________________
GP Address: _________________________________________________________________
GP Telephone Number: _______________________________________________________
Many thanks
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11.4
Appendix 4 – Recoding Patients Ethnic Category
Recording of Ethnic Category Information for Patients
In line with other healthcare providers, this hospital, is required by the NHS to collect
information about patients’ ethnic category or background. This information will help us plan to:



provide a better service
meet the needs of the community
ensure that everyone has equal access to the health care we provide
All the information we receive will be used and treated with the strictest confidence.
Note: We are not asking about citizenship or nationality, but about the ethnic category to which
you feel you belong. Providing this information is entirely voluntary, but it will help us to provide
a better service to all the patients that we treat. However, if you choose not to provide this
information then please be assured that the level of care given to you by the Trust will not be
affected in any way.
If you have any queries regarding providing the ethnic category you feel you belong to, please
ask a staff member. Otherwise, please tick the box next to the ethnic category you feel
you belong to;
Ethnic Category
Please
Tick
White British
White Irish
Any other White background
Mixed Black and White Caribbean
Mixed Black and White African
Mixed White and Asian
Any other Mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Black - Caribbean
Black - African
Black - Any other Black background
Chinese
Any other Ethnic category
Not stated
If you feel you are descended from more than one category, please identify the ethnic category
that you feel you most belong to, or choose the 'Any other ethnic category’ option.
Accident & Emergency Procedure Version 3.0
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11.5
Appendix 5 – Doctors Names and Identification Codes
Accident and Emergency Doctor Codes
Effective from: 5th February 2003
Code
Consultants
Mr Akbar
6043
Dr Dasan
6092
Mr Lelo
6058
Staff Grades
Mr Daghestani
6068
SHO’s
Daly, A
6114
Joseph, S
6115
Siddiqui, T
6116
Dutta, S
6117
Igbinosa, C
6118
Kapoor, A
6119
Bagree, S
6091
Bellam, Sunil
6103
Crida, Danielle
6100
Ellis, Jenny
6097
Hooker, Fiona
6094
Hughes, Sarah
6093
Khan, Taha
6101
Jones, Cheryl
6095
Moledina, Jamil
6099
Patel, Vishal
6096
Rehman, Rafiq
6102
Unnithan, Ashwin
6098
Accident and Emergency Doctor Codes continued
Trust Practioner
ENP’s/MIU Staff
GP’s (Mainly in MU)
Aziz, U
6123
Duggirala, N
6120
Deshpande, M
6121
Najjar, N
6122
Badcock, Sarah (ENP)
6073
Blakely, K (ENP)
6108
Buttery, Davina (ENP)
6074
Dopson, Amy (ENP)
6069
Galloway, Stuart (ENP)
6076
Hill, Richard (ENP)
6071
Holroyd, Kathy (ENP)
6054
Jewel, S (ENP)
6107
Lewis, Mandy (ENP)
6070
Linney, A (ENP)
6106
Matthews, Lynn (ENP)
6075
Monk, Dee (ENP)
6056
Scott, Ros (ENP)
6053
Vosper, Julie (ENP)
6072
Wood, Lisa (ENP)
6057
Evans, R (GP)
6302
Greenway, P (GP)
6303
Jenkins, M (GP)
6301
Ratti, B (GP)
6300
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11.6
Appendix 6 - ‘Non Urgent Case-note to be called’
REQUEST FOR NON-URGENT CASE-NOTES
To: Medical Records
Date Request Sent: _____________________
East Surrey *
Crawley *
Horsham *
Crawley *
Horsham *
*Delete as appropriate
From: Accident & Emergency Reception
East Surrey *
*Delete as appropriate
SURNAME
FIRST NAME
Accident & Emergency Procedure Version 3.0
CASE-NOTE
NUMBER
Page 53 of 59
DATE OF
REQUEST
11.7
Appendix 7 – Fracture Appointment List (Example)
MR STONE – HAND CLINIC
MONDAY PM
Date of Clinic: __________________________________________________________
Time
Surname
First Name
D.O.B.
Date Appt.
Made
2.00
2.10
2.20
2.30
2.40
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Referred
from
11.8
Appendix 8 - Review Clinic Appointment List (Example)
MR AKBAR A/E CLINIC
DATE:
Time
DAY:
Surname
First Name
D.O.B
Appointment
Made
9.00
9.10
9.20
9.30
9.40
9.50
10:00
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Comments
11.9
Appendix 9 - Case-note Tracking Slip
Case-note Tracking Slip
This is to inform the person currently responsible for the case-notes that you are removing a set of
case-notes and that you will track them on the PAS to either yourself or your department.
Patient Details
Name: ………….………………………………………….……………..…………….…………….…..…….…
DOB: ..………………………………….………………….…………….………….…………………….……...
Hospital Number: ………………………..……….…………………..…………………….………………..…
Details of Person removing Case-notes
Name: ……………………………………….……….……………….……………….…………….….………...
Department: ………………………………………..….……………………………………………..………....
Time Removed: ………………………………….………..……………………………………………….…...
Reason for Removal: …………………………………………..….………………….…………………….....
Date: …………………………………………………
Tick once checked on the PAS: .…………….
Case-note Tracking Slip
This is to inform the person currently responsible for the case-notes that you are removing a set of
case-notes and that you will track them on the PAS to either yourself or your department.
Name: ………….………………………………………….……………..…………….…………….…..…….…
DOB: ..………………………………….………………….…………….………….…………………….……...
Hospital Number: ………………………..……….…………………..…………………….………………..…
Details of Person removing Case-notes
Name: ……………………………………….……….……………….……………….…………….….………...
Department: ………………………………………..….……………………………………………..………....
Time Removed: ………………………………….………..……………………………………………….…...
Reason for Removal: …………………………………………..….………………….…………………….....
Date: …………………………………………………
Accident & Emergency Procedure Version 3.0
Tick once checked on the PAS: .…………….
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11.10 Appendix 10 – Request for Personal Information
SURREY & SUSSEX HEALTHCARE NHS TRUST
AHRA 1990/DATA PROTECTION ACT 1998 – Sect 7
REQUEST FOR PERSONAL INFORMATION (SUBJECT ACCESS)
TO: Medical Records/X-ray/Physio/Human Resources/Other-Please specify:Caterham Dene/Crawley/Dorking/East Surrey/Horsham/Oxted (Please delete as necessary)
DATA SUBJECT
Name in full
Previous Name(s)
Address
Date of Birth
Details of Information Required
I wish to see/obtain a copy of the health records/personal data held
(Please delete as necessary)
INDIVIDUAL MAKING REQUEST (if different from above)
Name in full
Address
Relationship to Data Subject
PTO
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DECLARATION
I declare that the information given by me is correct to the best of my knowledge and that I am
entitled to apply for access to the health record/personal data referred to above under Access to
Health Records Act 1990 or the Data Protection Act 1998.
*
I am the patient/data subject
*
I have been asked to act by the patient and attach the patient’s written consent
*
I am acting in loco parentis, the patient is under 16 and is not capable of understanding the
request or has consented to my making this request
*
I am the deceased patient’s personal representative and attach confirmation of my
appointment
*
I have a claim arising from the patient’s death and wish to access information relevant to my
claim on the grounds that:
………………………………………………………………………………….
………………………………………………………………………………..…
Signed ………………………………………
Date ………………………………
* Please delete as appropriate
CERTIFICATION
I certify that I have known the applicant for ………….. years as an * employee/client/patient/personal
friend and have witnessed the applicant sign this form. I am not related to the applicant.
Name
……………………………………….……….
Address
………………………………………………..
………………………………………………..
……………………………………….……….
Signed………………………………………
Date …………………………..…
WARNING
You are advised that the making of untrue statements to secure access to
personal information to which you are not entitled is a criminal offence.
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11.11 Appendix 11 – Casualty card Sample Checking Sheets
ACCIDENT & EMERGENCY SAMPLE CHECKING AUDIT
Write Y (Yes) or N (No) if the information is on the CAS card or not. If the code on the cas card is not completed (N), then skip the relevant checking box for PAS.
Write Y if the code in the PAS box the same as that on the cas card, if the code is not the same check 'wrong code' or check 'incomplete'. If you know the correct information please complete on PAS.
Patient Group
PAS
Treatment
PAS
Date of sample selection:
Wrong Code
Incomplete
Code (Y or N)
The Same (Y)
Wrong Code
Incomplete
Code (Y or N)
The Same (Y)
Wrong Code
Incomplete
Disposal
PAS
The Same (Y)
Card
Code (Y or N)
D
Card
Incomplete
C
Anatomical Site
PAS
Wrong Code
Incomplete
B
Card
The Same (Y)
Wrong Code
A
General Diagnosis
PAS
Code (Y or N)
The Same (Y)
Card
Code (Y or N)
Card
A
B
C
D
A
B
C
D
A
B
C
D
A
B
C
D
Patient No. and comments (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Total (add
Y's and/or
ticks only)
3
Name of checker: …………………………………………………….………………………
Signature: …………………………………………………. Date: ………. / ………. / ………..
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