Outpatient Clinic Procedure
Version:
Issue Date:
Version 2.0
Responsible Person:
Anita Gurcan
Outpatient/Medical Records Manager
Approved by:
Mary Garside
Patient Access Manager
4th September 2003
Review Date:
4th April 2004
DO NOT USE THIS PROCEDURE
AFTER THE REVIEW DATE
Contents
1 Introduction .................................................................... 4
1.2
Purpose ................................................................................................... 4
2 Clinic Preparation........................................................... 5
2.1
2.2
2.3
2.4
2.5
Advance Preparation ............................................................................... 5
Description of Lists .................................................................................. 5
Preparing the Oupatient Reception Area ................................................. 6
Case-note availability............................................................................... 7
Late Bookings .......................................................................................... 7
3 General Procedures ....................................................... 8
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
Overseas Patients ................................................................................... 8
Duplicate/Multiple Records ...................................................................... 8
Incorrect Names and/or Dates of Birth..................................................... 9
Late Arrivals ............................................................................................. 9
Patient Arrives on wrong day ................................................................... 9
Unexpected Patients.............................................................................. 10
Walk in Patients ..................................................................................... 10
Non-recepted Outpatient Clinics ............................................................ 11
Clinic Cancellation ................................................................................. 11
4 Welcome and Check-in ................................................ 12
4.1
4.2
4.3
Check-in Patients with Appointments .................................................... 12
Updating patient details ......................................................................... 15
Check-in Walk in Patients ...................................................................... 16
5 Checking out Patients .................................................. 23
5.1
5.2
5.3
Checking a Patient Out .......................................................................... 23
Follow-up Appointments ........................................................................ 25
Patient Transport ................................................................................... 27
6 End of Day PAS Process ............................................. 29
6.1
6.2
6.3
6.4
6.5
6.6
6.7
Completing End of Day .......................................................................... 29
End of Day process for a patient with no account number..................... 30
Discharing a patient that has had an outpatient appointment ................ 30
Discharing a Outpatient episode ............................................................ 32
Patient Did Not Attend (DNA) ................................................................ 33
Outpatient Clinic Coding ........................................................................ 34
Sample checking ................................................................................... 35
7 Case-notes................................................................... 36
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8 Security and Confidentiality ......................................... 36
9 Contacts ....................................................................... 37
10
Appendices ............................................................... 38
10.1
10.2
Appendix 1 - Clinic Preparation Check List............................................ 38
Appendix 2 - Highlighting Possible Duplicates/Multiples/Old Prefix’s
Memo..................................................................................................... 39
Appendix 3 - Patient Detail PAS Change Required Alert ....................... 40
Appendix 4 – Clinic Cancellation/Reduction Form ................................. 41
Appendix 5 - Application for Additional GP’s on the PAS ...................... 42
Appendix 6 - Patient Details Form ......................................................... 43
Appendix 7 – Additional Code Request Form ........................................ 45
10.3
10.4
10.5
10.6
10.7
Written by:
Anita Gurcan – Outpatient/Medical Records Manager
Jane Andoe – Outpatient Improvement Manager
Stephanine Saunders – Outpatient and Medical Records Manager
Nicola Gould – Data Accreditation Facilitator
Vanessa Underhay – Data quality Manager
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1
Introduction
1.1.1
This procedure has been designed to clarify the required standards in
all aspects of the administration and management of Outpatient Clinics.
It places obligations primarily on the Outpatient and Medical Records
staff, but for its successful implementation requires the co-operation of
medical, nursing and managerial staff.
1.1.2
The Outpatient and Medical Record Departments are responsible for
the administrative tasks relating to the delivery and running of
Outpatient Clinics at all sites across the Trust, with the exception of
Women and Children directorate, Dental Department, X-ray,
Haematology and various Therapy departments.
1.1.3
For these devolved departments, outpatient and medical records will
undertake a monitoring role to ensure that Trust standards are met.
1.2
Purpose
1.2.1
The purpose of these procedures is to give detailed instructions on how
to undertake the full range of duties that are necessary to ensure that
outpatient clinics run smoothly. This means that patient case-notes are
available and well prepared; patient’s are greeted and assisted politely
and efficiently when they attend one of the Trust’s Outpatient clinics and
that all relevant information is recorded both in the health record and on
the PAS prior to, during and at the end of clinics.
1.2.2
As with many other procedures the Outpatient Clinic procedures will be
subject to revision over the next few months as part of the re-design
programme that is underway through the Outpatient/Medical Records
Improvement Plan.
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
PAS Codes and Key Strokes Booklet
Case-note tracking - Batch Transfer
Outpatient Booking
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2.1.1
2
Clinic Preparation
2.1
Advance Preparation
The following tasks will be carried out by the Medical Records staff in
line with the Medical Records Procedures in advance of all Outpatient
Clinics:










Outpatient Clinic List
Distribution of Clinic Lists
Locating case-notes
Retrieving case-notes for Outpatient Clinics
Preparing case-notes for Outpatient Clinics
Updating patient information on the PAS and in case-notes
Preparation of case-notes for Outpatient Clinic
Availability of case-notes for Outpatient Clinics
Late additions to an Outpatient Clinic
Late bookings for an Outpatient Clinic
2.1.2
As Medical Records staff prepare case-notes for the Outpatient Clinic,
they must complete a Clinic Preparation Checklist (Appendix 1). This
list is passed to Outpatient Reception staff to complete during and after
the Outpatient Clinic.
2.1.3
Medical Records staff will remove any case-notes for patients who have
been cancelled, and these will be returned to the library prior to the
case-notes for a clinic being collected or delivered.
2.2
Description of Lists
2.2.1
Pull Lists – are lists of patients that are attending appointments on a
stated date in the order of Consultant with the location of the case-notes
identified. These are printed off 3 – 5 days before the Clinic.
2.2.2
Doctors List/Clinic List - are lists of patients in appointment time order
that are due to attend an Outpatient Clinic. A copy of the Doctors list is
given to the x-ray department to enable them to pull x-rays for the clinic.
The Doctor/Clinic List will be run 3 - 5 days before the clinic date and
again the day before the clinic.
Note: East Surrey doctor’s lists are printed onto three-part paper, one
copy is retained by the medical records staff, one copy given to x-ray
(only orthopedic clinics) and one copy placed in the consultant’s pigeon
hole in the Central Booking Office.
Crawley & Horsham must print off individually the number of required
lists.
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2.2.3
Clinic Booking Summaries – are lists of Consultants Clinics showing
appointment availability for the next 12 months. This report is
automatically produced by the PAS and is used by the consultant in
clinic to plan follow-up appointments for patients.
2.3
Preparing the Oupatient Reception Area
2.3.1
Outpatient Reception staff must ensure that the doctor’s nameplates
and case-note shelving are updated at the beginning of each clinic
session.
2.3.2
Outpatient Reception staff will collect the relevant clinic list summary
and case-notes prior to the clinic session start time. Alternatively,
Medical Records staff can deliver the case-notes to the Outpatient
Clinic reception.
Note: Case-notes must always be transported in trolleys for health and
safety reasons.
2.3.3
Any case-notes prepared for an outpatient clinic must not be removed
from Medical Records without authorisation from a Supervisor.
2.3.4
On arrival at clinic, case-notes must be laid out in alphabetical order in
the relevant reception area.
2.3.5
Lists are dealt with in the following way:

‘Pull List’ and the original ‘Doctor/Clinic List’ must be kept
together with the case-notes and then returned with the Clinic
Preparation Checklist to the Medical Records Manager for audit
purposes

Note: These lists must be kept for 4 months after the date of the
clinic

Other copies of the latest ‘Doctors/Clinic List’ must be placed in
the individual doctors tray ready for the nurses to collect and
distribute

‘Clinic Booking Summaries’ are to be placed in the individual
doctors tray ready for the nurses to collect and distribute.
Alternatively, these lists can be given directly to the doctors to
ensure they use them when planning follow up appointments for
patients
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2.4
Case-note availability
2.4.1
Outpatient reception staff must ensure that there is a batch of casenotes for each clinic.
2.4.2
At the start of the clinic, there must be a set of case-notes for every
patient attending the clinic. If there is not a set of case-notes for every
patient, this must be recorded on the Clinic Preparation Checklist with
the reason why the case-notes where not available.
2.4.3
When a set of case-notes for a patient is not available at the start of the
clinic, medical records staff must have made up a temporary set of
case-notes.
2.4.4
Every case-note must be properly prepared for every outpatient clinic
by the following deadline:

For morning clinics, all case-notes must available and fully
prepared for the clinic by 4pm the previous day

For afternoon clinics, all case-notes must available and fully
prepared for the clinic by 11am on the day of the clinic
2.5
Late Bookings
2.5.1
A late booked appointment is when an appointment is booked within 48
hours before the start of the outpatient clinic.
2.5.2
Any person making a late booking must notify the Medical Records
Department as soon as the appointment has been made to enable
Medical Records to locate the patient’s case-notes.
2.5.3
Medical Secretaries who make late bookings are requested to provide
the case-notes to the Outpatient Reception or Medical Records
Department.
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3
General Procedures
3.1
Overseas Patients
3.1.1
Overseas Patient - Any person who has not resided in this country for
a continuous twelve months.
3.1.2
All patients must be asked, when they present themselves at the Trust,
where possible if they have resided in this country for longer than 12
months.
3.1.3
If reception staff believe that either a new or existing patient could be an
overseas patient they must contact the Overseas Patient Officer,
Income Recovery Department on ext 1702.
3.1.4
If no one answers the telephone or it is outside of office hours (before
9am or after 5pm Monday – Friday), a message must be left on the
answerphone, stating the outpatient department and the patient’s casenote number.
3.2
Duplicate/Multiple Records
3.2.1
When searching the Master Patient Index (MPI) for a patient and the
PAS displays either a:
3.2.2
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.
3.2.3
Duplicate Record - more than one record for a patient on the PAS are
identified.
Note: In these circumstances record the attendance against the record
with the most recent activity.
3.2.4
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
options.
3.2.5
If a patient is identified as having Multiple Patient Records, Duplicate
records or an Old case-note prefix it must highlighted to the Medical
Records
Department
using
the
‘Highlighting
possible
Multiple/Duplicate/Old Prefix PAS entries’ memo (Appendix 2).
3.2.6
If possible a front sheet for each of the entries on the PAS must be
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printed off and attached to the memo, (Appendix 2), and sent to the
Medical Records Manager.
3.3
Incorrect Names and/or Dates of Birth
3.3.1
If when checking a patient into an Outpatient clinic and it is noted that
the patient has either incorrect name and/or date of birth the Medical
Records department must be notified.
3.3.2
Only authorised personnel can change these fields on the PAS.
Complete and attach to the front of the case-note a ‘Patient Detail PAS
Change Required Alert Form’ (Appendix 3).
3.4
Late Arrivals
3.4.1
Patients arriving late must be highlighted to the nurse in charge of the
clinic by reception staff, the nurse will discuss this matter with the
Consultant who will decide if the patient can still be seen. The nurse
will inform the reception staff of the Consultant’s decision.
3.4.2
Sensitivity must be displayed when dealing with late arrivals and
discretion exercised in certain circumstances beyond a patient’s control
e.g. transport delays.
3.4.3
If the decision is made that the patient cannot be seen, the reception
staff must confirm whether the patient is a new patient or a follow-up. If
the patient is a follow-up, the patient will be informed when the next
available appointment is, and if acceptable the appointment will be
booked for the patient.
3.4.4
If it is a new patient, either the Outpatient or Medical Records Manager
must be informed, so they can arrange an appointment before the
patient leaves the Trust.
Note: When recording Outcomes, the patient must be checked in and
then checked out with the outcome as ‘Attended – not seen’.
3.5
Patient Arrives on wrong day
3.5.1
If a patient arrives on the wrong day, the receptionist must talk to a
nurse/consultant to see if the patient can be seen.
3.5.2
Patient Can be Seen -If the Consultant decides that they can see the
patient, the patient must be checked in as a ‘Walk in Patient’, see
section 4.3 Check-in Walk in Patients (Page 16).
Note: Ensure that on Screen 7a the relevant referral is selected.
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3.5.3
If the patient has arrived before the day of their appointment, this
appointment on the PAS must be deleted.
3.5.4
Patient Cannot be Seen – If the patient cannot be seen, the patient
must be informed of this decision. If the patient has a future
appointment, the patient must be provided with the full details of this
appointment.
3.5.5
If the patient has missed their appointment, the patient should be
informed that they will be notified in writing of another appointment date.
3.6
Unexpected Patients
3.6.1
When a patient arrives at the Outpatient Reception and is not expected
the Reception staff must investigate as to whether the patient should be
seen. This should be done by checking the PAS to see if the patient
has a late booked appointment or by asking the patient who they should
be seeing/who contacted them regarding the appointment and then
contact the relevant team to check this.
3.6.2
If appointment is confirmed, reception staff must contact Medical
Records to request the patient’s case-notes.
3.6.3
Once the appointment is confirmed, if the appointment is on the PAS,
the patient must be checked in, go to section 4.1 Check-in Patient’s with
appointments (Page 12).
3.6.4
If the patient’s appointment is not on the PAS and the patient must be
checked in as a Walk In Patient, go to section 4.3 Check-in Walk in
Patients (Page 16).
3.7
Walk in Patients
3.7.1
Walk in Patients are patients that have been referred at short notice and
the referral is not recorded on the PAS due to the timing.
3.7.2
Most walk in patients will be attending a walk in clinic, however any
walk in patients for other clinics should have been arranged between
the referrer and the relevant Consultant.
3.7.3
If the consultant agrees to see the patient the receptionist will check the
patient in following the ‘Walk-in procedure’, go to section 4.3 Check-in
Walk in Patients (Page 16) and then request the case-notes from the
Medical Records Department.
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3.8
Non-recepted Outpatient Clinics
3.8.1
Any outpatient clinics that are not recepted either by clerical or clinical
staff must forward all the paper work (Appointments slips, clinic/doctors
list with outcomes, outpatient clinical coding sheets, Clinic preparation
check list) to the medical records manager as soon as possible after the
Outpatient Clinic.
3.8.2
Medical Records will process these records through the End of day
process to ensure that the PAS is accurate and up to date.
3.8.3
East Surrey Medical Records department are responsible for coding the
unmanned Outpatient Clinics.
3.8.4
The Clinical Coding department is responsible for ensuring that all
Outpatient Clinic Coding sheets are kept up to date.
3.9
3.9.1
Clinic Cancellation
If an outpatient clinic needs to be reduced in size or cancelled a Clinic
Cancellation form (Appendix 4) must be completed and sent to the:



Central Booking Office Manager
Medical Records Manager on the appropriate site
Outpatient nurses on the appropriate site
3.9.2
The Clinic Cancellation form must be sent to the individuals listed above
at least six weeks before the date of the clinic.
3.9.3
If the Clinic Cancellation form is completed within six weeks of the date
of the clinic, the form must also be sent to the Directorate head.
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4
4.1
Welcome and Check-in
Check-in Patients with Appointments
4.1.1
Patients’ will be welcomed on their arrival at clinic and their name will
be manually ticked off on the clinic list and the patients case-note
removed from the shelving.
4.1.2
Once the above has been completed the patient must be checked in on
the PAS.
4.1.3
Within the PAS Main menu select the ‘Outpatient Functions’ menu,
press return.
Select the ‘Check In–Out’ menu, press return.
Screen 1
Type ‘P’ to search for the patient, press return.
Note: All outpatient appointments must always be booked in through
the option ‘P’ to search for the patient first, this enables the patient’s
demographics to be checked and updated where necessary.
Enter Unit No, name, ‘=’ for current – at this prompt enter the
patient’s case-note number, or search for the patient.
4.1.4
To locate a patient on the PAS, the following steps must be followed:
4.1.5
First Attempt: enter the patient’s case-note number if known, press
return.
4.1.6
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:
4.1.7
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.
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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
Screen 2
This screen will display a list of any patients that match the search
criteria.
4.1.8
If the patient is not listed, the search must be undertaken again as the
patient has an appointment so the patient must be on the PAS.
Note: From the list of patients if any duplicate/multiple/old prefix
records are identified for the patient then the Medical Records
Department must be notified see section 3.2 Duplicate/Multiple Records
(Page 8).
Select the relevant patient.
Screen 3
This screen will display the patient’s demographic details. All these
details must be checked with the patient.
Note: It is important that the patient provides their details to staff, rather
than staff telling the patient their details.








4.1.9
Title
Name
Address
Date of birth
Telephone Number(s) – Home, Work & Mobile
GP
‘Next of Kin’
Ethnic Category
Whenever possible the patient’s ethnic category must be recorded for
every patient that attends the Trust for treatment.
4.1.10 If the indicated GP is not on the PAS enter ‘9995’ (Unknown GP Code)
and complete the ‘Application for Additional GP on the PAS’ Memo
(Appendix 5).
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Screen 4
This screen will display any future appointments relating to the patient.
At the following prompt select the relevant appointment.
Enter choices (e.g. 1,7,5-9) or ’-‘ choices to remove – select the
relevant appointment.
The selected appointment will now be highlighted – press return.
Note: If there are joint appointments these can be selected
simultaneously.
Screen 5
Enter cancel (C), edit (E), check in (I), check out (O) or continue
(NL) -- at the prompt enter ‘I’ (this is always I as the patient is being
checked in).
Note: The following prompt will only come up for patients with an
appointment type of ‘OPR’ Do you wish to admit this patient Y/N - at
the prompt type ‘Y’.
Screen 5a
This screen shows the patient type and OPG must be selected at the
following prompt.
For all patients with appointment type of ‘OPG’, the PAS will go to
Screen 8.
Select new type, or NL for original (OPR).
Screen 6
This screen will display any duplicate/multiple case-note number that
has been merged for the patient – this screen can be by-passed.
Screen 7
This screen must be used to change any patient details if required e.g.
next of kin, emergency contact numbers. Once the changes have been
entered, type ‘Y’ at the prompt.
Note: It is very important that the Next of Kin details are correct for
every patient.
Do you wish to revise the admission details? (Y/N) (N)--
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Screen 7a – if ‘Y’ is selected the PAS will go to the revise admission
process menu.
Select either menu ‘Emergency Contact Number’ or ‘Relative Page’.
Once the required changes have been made press return on the menu
page.
Screen 8
This screen shows the appointment that the patient has been checked
into and the status. Ensure the status is marked ‘F/I’. If this is not the
case, at the prompt select the appointment number, if ‘F/I’ is shown
press return.
Enter choices (e.g. 1,7,5-9) or’-‘ choices to remove.
The patient has now been checked in and the PAS goes back to
screen 1. The next patient can be checked in.
Note: Staff must ensure that the patient is booked into the correct
appointment type on the PAS.
Example: If a patient has been booked into a Ex Ward Appointment
and the patient is attending as a follow-up appointment, the
appointment must be changed on the PAS to a Follow-up appointment.
4.2
Updating patient details
4.2.1
If there are any changes to the patient details other than the date of
birth and patient’s name, the details must be updated on the PAS
immediately.
4.2.2
When changes have been made to a patient’s record on the PAS, if
possible a new front sheet and labels must be printed off and filed in the
case-notes. Ensure the old front sheet and identification labels are
removed and destroyed correctly.
4.2.3
If it is not possible to print out front sheets and labels immediately then
the following action must be taken:
4.2.4

a manual update must be made in the patient case-notes on the
front sheet and the existing labels removed from inside the casenotes

the Patient Detail Change Alert form, (Appendix 3) must be
completed and placed on the front of the case-note to alert staff
of a change of patient details
If the patient has identified any special requirements, these
requirements must be entered into the comment field and be brought to
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the attention of medical staff who are responsible for the patient’s care.
4.2.5
Once all changes and checks have been undertaken the patients casenotes must be placed into the relevant doctors tray(s).
4.2.6
Patient’s will be directed to the relevant clinical waiting area and alerted
to any potential delays or any other information that is relevant.
4.3
Check-in Walk in Patients
4.3.1
The Consultant will make the decision whether the Walk-in patient can
be seen.
4.3.2
The receptionist must ask the Patient the following questions:





Whether they have been to the Trust before (this would include
any hospital site within the Trust)
Hospital/Unit Number (if known)
Full name
Date of birth
Has the patient been referred by their GP or does the patient
have a verbal appointment
4.3.3
All walk in patients must be asked to complete a ‘Patient Details Form’,
(Appendix 6).
4.3.4
The information provided on the patient details form must be used to
book the patient into the PAS.
Note: If the patient has attended the Trust before, use the completed
patient details form to update the patient’s record on the PAS.
4.3.5
The receptionist must manually add the patients name on the
Doctor/Clinic List and case-notes requested/made up as appropriate.
4.3.6
Within the PAS Main menu select the ‘Outpatient Functions’ menu.
Then select the ‘Walk-in’ menu.
Screen 1
Enter appointment date [T] – use the default of ‘T’ for today or enter
the date of the required appointment (the option of typing the date
should be used when entering back data).
Screen 2
This screen will display the date that has been selected.
Enter Resource – at this prompt either search on the consultant’s
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name or resource number if known.
Screen 3
This screen will display a list of potential clinics that are linked to the
above search with the various staff types i.e. Consultant, Registrar,
SHO.
Enter choice – at this prompt type the number of the required clinic.
Screen 4
This screen will display the actual clinic and date of clinic – ensure that
these are correct before going any further.
Enter Unit No. name, ‘=’ for current – search for the patient.
4.3.7
First Attempt: enter the patient’s case-note number if known, press
return.
4.3.8
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:
4.3.9
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
Screen 5
This screen will display a list of patients.
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Note: If the patient is not found on the first search then a second
search must be undertaken.
4.3.10 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.
4.3.11 If the patient is not on the PAS, Select #, ‘A’ to add patient – at this
prompt select the number that corresponds to the required patient or if a
patient needs to be added to the PAS select ‘A’.
Note: From the list of patients if any duplicate/multiple/old prefix
records are identified for a patient then the Medical Records
Department must be notified see section 3.2 Duplicate/Multiple Records
(Page 8).
If the patient is on the PAS, the PAS will go to Screen 6. If a patient
needs to be added to the PAS, the PAS will go to Screen 5a.
Screen 5a
This screen will display an empty Patient details page. Details from the
completed ‘Patient Details Form’ must be used to complete this page.











Surname
Christian name
Title
NHS Number – if known
Sex
Date of Birth
Ethnic Category
Address Telephone number (s) – Home, Work & Mobile
Registered GP
Next of Kin Information
If the patient does not reside in Great Britain the home country address
needs to be obtained, see section 3.1 Overseas Patients (Page 8).
If the indicated GP is not on the PAS enter ‘9995’ (Unknown GP Code)
and complete the ‘Application for Additional GP on the PAS’ Memo
(Appendix 5).
All other fields shown on this screen will be bypassed and no entries
made.
Once these have been completed, ‘Accept this screen? Y/N’, press ‘Y’
to accept the screen. The PAS will go to Screen 7.
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Screen 6
This screen is the Patient details page and the details shown must be
checked with the patient and changes made as necessary.
Once these have been completed, ‘Accept this screen? Y/N’, press ‘Y’
to accept the screen.
Screen 7 - Unscheduled Appointment page
Visit Type – press return to accept the default of ‘~WI’ (this indicates a
walk-in patient).
Appointment – press return to accept the default of ‘current day and
time’.
New Visit – press return to accept the default of ‘N’ (this is always the
default as otherwise there will be no account number (Episode number)
generated for this episode).
Screen 7a
This screen will only be shown if the patient has any current referrals on
the PAS – if there is a referral for the same consultant then this must be
selected.
Select account number, ‘N’ to create new account – if one of the
referrals listed is not selected, ‘N’ the PAS will go to Screen 8 - if a
referral is selected PAS will bypass the below screens and go to
Screen 7 continued.
Screen 8
This screen will display a list of all visit types.
Enter Choice – this will always be ‘OPG-Outpatient Attendance’.
Screen 9
Admitting Cons/GP – this is always be the resource code of the
Consultant in charge of the clinic that the patient has been booked into
regardless of the type of staff member seeing the patient.
Referring GP – this field must be completed with the patient’s GP
details.
Current Consultant – this is always the same consultant as the
Admitting Con/GP.
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Specialty – type ‘-‘ to bring up the table of specialties linked to the
Consultant - select the relevant specialty.
Location – enter the location of the outpatient clinic.
Admitting Diagnosis – bypass this field.
Working Diagnosis – this field is automatically filled in from the
information entered in the ‘admitting diagnosis’ field.
Smoker – if the information is provided, please complete the field, if the
information is not provided bypass the field.
Allergies - only complete this field when instructed by a Healthcare
professional.
Comment field – this should hold as much information as possible i.e.
‘Patient From A&E’, ‘Patient from GP with letter’, ‘Patient sent from
ward’.
Surgery Scheduled – bypass this field.
Date – bypass this field.
ELOS – bypass this field.
Case Category - bypass this field.
Acci – bypass this field.
Organ - bypass this field.
AD’s - bypass this field.
Pat/Admin Category – type ‘-‘ and select the relevant option from the
list.
Once these have been completed, ‘Accept this screen? Y/N’, press ‘Y’
to accept the screen.
Screen 10
This screen is the Miscellaneous page where any other relevant
information must be entered.
Prev Visit – always the default of ‘N’.
Visit Type – type ‘-‘ and select the option Outpatients.
Referral Date – type ‘T’ for today or type today’s date.
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Referral source – type ‘-‘ and select the relevant option from the list
(this indicates who sent the patient for an outpatient appointment).
Referral Reason – type ‘-‘ and select ‘Advice and Consultation’.
Overseas Patient – the Income Recovery Manager completes this field
on the PAS.
Admission type – type ‘-‘ and select from the list ‘Urgent’.
Admission source - type ‘-‘ and select the relevant option this could be
A&E, ward, usual residence etc.
All other fields shown on this screen are bypassed and no entries
made.
Once these have been completed, ‘Accept this screen? Y/N’, press ‘Y’
to accept the screen.
Screen 11
This screen is the Outpatient Admittance page most of these fields will
have been automatically completed.
Account Number – press return – this will enter a PAS generated
number for the patient in the background.
ROI Consent – press return to accept the default of ‘N’.
All other fields shown on this screen will be bypassed and no entries
made.
Once these have been completed, ‘Accept this screen? Y/N’, press ‘Y’
to accept the screen.
Note: If the patient has visited the Trust previously but did not have any
case-notes made up, the PAS will ask the following question.
Accept E SURREY as the filing location for chart (Y/N) – the filing
location for the case-notes is dictated by the address of the patient
e.g. Crawley address, the filing location is Crawley; Redhill address, the
filing location is East Surrey. Selecting ‘No’ will display a list of
alternative filing sites, select the correct site.
If case-notes have not been made up for the patient, outpatient
reception staff must send a request to the Medical Records Department
for a new set of case-note to be made up.
A message is displayed ‘Patients assigned account number
xxxxx-xxxxx, press NL’ – press return to accept the new account
number.
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Screen 7 – continued
Visit Reason – press return to accept default of ‘WALK-IN’.
Comment Field – this should provide as much information as possible
i.e. ‘Patient From A&E’, ‘Patient from GP with letter’, ‘Patient sent from
ward’.
Referring Cons/GP – this field is automatically completed.
Priority – type ‘-‘ and select Urgent.
All other fields shown on this screen will be bypassed and no entries
made.
‘Accept this screen? Y/N’, press ‘Y’ to accept the screen.
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5
5.1
Checking out Patients
Checking a Patient Out
5.1.1
After the patient has been seen, the consultant will indicate on an
appointment slip any future appointment requirements or advise the
patient that no further appointment is required.
5.1.2
The clinic nurse will ask the patient to return to the reception desk with
the slip, together with a signed transport form if necessary. If the
receptionist is not present at the end of the clinic, the nurse must retain
the appointment slip and explain to the patient that they will be
contacted regarding a future appointment.
5.1.3
If a further appointment is required the receptionist will offer the patient
a choice of appointments within the appropriate timescale and a
‘booked’ appointment will be recorded on the PAS.
5.1.4
When entering follow up appointments on the PAS the comment field
must be completed with as much information as possible regarding the
booking of the future appointment.
5.1.5
Patients requiring hospital transport must have this recorded on the
PAS at the time of booking the appointment.
5.1.6
Once the appointment has been booked an appointment card/letter
must be handed to the patients stating the time and date of the
appointment.
5.1.7
Then select the ‘Check In–Out’ menu.
Screen 1
This screen is used to search for the patient – select ‘P’ to search by
the patient.
Enter Unit No, name, ‘=’ for current – at this prompt enter the patient
case-note number, or the patients name, or the patients date of birth.
Screen 2
This will give a list of any patients that match the search criteria.
Select the relevant patient – if the patient is not listed, the search must
be undertaken again as the patient has had an appointment so they
must be on the PAS.
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Screen 3
This screen displays the patient’s details; these must be checked with
the patient to ensure that the correct patient has been selected.
Screen 4
This screen will display all appointments for the patient for today
regardless on whether the patient was checked in or not. At the prompt
select the relevant appointment.
Enter choices (e.g. 1,7,5-9) or’-‘ choices to remove –
Note: If the status is not ‘F/I’ then the patient has not been checked in
and as such cannot be checked out. Check the correct patient has
been selected, if so, the patient must be checked in before being
checked out – see section 4.1 Check-in Patients with appointments
(Page 12).
Screen 5
Enter cancel (C), edit (E), check in (I), check out (O) or continue
(NL)-- - At the prompt type ‘O’ for check out.
Enter outcome of attendance – type ‘-‘ and select the relevant
outcome as indicated by the consultant i.e. Further Appointment Given,
Placed on Inpatient Waiting List.
Note: The possible outcomes for an Outpatient appointment are:
Further Appointment Given
Appointments (Page 25).
–
so
to
section
5.2
Follow-up
Appointment Pending – this should be selected if the patient has
another appointment already booked for the same consultant.
Appointment Given as necessary – Do not use this option.
Outpatient Discharge – this field only records the Outcome of the
appointment, the patient must be discharged separately, see section
6.3 Discharging a Patient that has had an Outpatient appointment
(Page 30).
(WA’s) only treatment complete – Do not use this option.
Placed on Inpatient Waiting List – this should be selected if the
patient is going to be placed on the Inpatient waiting list.
Admitted from clinic - this should be selected if the patient has been
admitted to the Trust from the outpatient clinic.
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Attended – not seen – this is selected if the patient attended and was
not seen by the consultant.
Ref’d to other Cons (this unit) – this is selected if the patient attended
and has been referred to another Trust consultant.
Ref’d to other provider – this is selected if the patient is referred to
another Trust for treatment.
Attended – did not wait – this option is select if the patient attended,
but did not wait to be seen.
Mr Banners Orthodontic W/List - this should be selected if the patient
placed on Mr Banners Orthodontic W/List.
Dermatology SOS – this should be selected if the patient is classified
as Dermatology SOS.
Outcome not known – this is selected if the outcome of the patient’s
appointment is not know.
Note: Completing the outcome of the appointment in the Outpatient
function does not complete the action in the appropriate function on the
PAS.
Example: Patient Outcome is: Placed on Inpatient Waiting List. The
outcome ‘Placed on Inpatient Waiting List’ is selected, but the patient
must also be placed on the waiting list. This task is undertaken by the
Waiting List office.
5.2
Follow-up Appointments
5.2.1
Once the patient has seen the clinical staff if a follow-up appointment is
required they will be given an appointment slip and asked to go to the
reception.
5.2.2
Where possible patients that go to the reception desk to make their
follow-up appointment will be given a choice of when the appointment
would be.
5.2.3
Where the reception is not manned, some patient’s appointment slips
will be left over. The follow up appointments must be for the patient and
an appointment letter/card sent in the post to the patient.
5.2.4
Select option ‘Further Appointment Given’.
Screen 6
Book a follow up appointment for this patient? (Y/N) [Y] – type ‘Y’,
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Enter the resource or ‘=’ for current consultant [*] – on the
appointment slip provided by the consultant/nurse it will be indicated
what the resource is.
Screen 7
This screen will show a list of clinics linked to the resource.
Enter choice - Select the relevant clinic.
Note: Only when necessary should staff book across Trust sites. If the
patient is to be seen on another site, the patient will be informed that
they will receive their next appointment date and time in the post.
Note: Ensure that the correct address for the patient is recorded on the
PAS.
Screen 8
Enter appointment date or calendar (C) – type in the relevant date or
time period e.g. 170803 or +6w for an appointment in 6 weeks time.
Screen 9
This screen will display appointment types and which are vacant.
Appointment Types:
F = Follow Up Appointment
N/P = New Appointment
A&E = A&E patients only
The next column has heading Pt/Fd. Pt = patient, fd = filled, fd
indicates that the appointment slot has been taken.
Select appt time, new date, view (V), modify (M) of calendar (C) – if
there is an appropriate appointment type available, type in the
appointment time e.g. 1225.
If the correct appointment type is not available, press return to continue
going through the calender for a date that has the correct appointment
type.
The PAS will display a message stating the time and date of the
appointment. To confirm the appointment, type ‘Y’, press return.
Note: If the requested appointment time is for a clinic that is already
fully booked, staff must discuss with the doctor when they would like to
see the patient.
Note: Only a supervisor can book an appointment into a fully booked
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clinic; refer this appointment booking to a supervisor.
Screen 10
The PAS will display a message ‘Proceed with making the
appointment? Y/N’, type’Y’.
Visit reason – press return to automatically fill in the field, it will display
the appointment type that has been selected.
Comment Field – this should hold as much information as possible i.e.
‘gap between appointments i.e. 3 months’, ‘appointment after scan’.
Transport – if a transport request form has been completed by the
nursing staff - type ‘-‘ to select the relevant option otherwise this will be
bypassed, see section 5.3 Patient Transport (Page 27).
Priority – type’-‘ and select Routine unless otherwise indicated on the
appointment slip.
All other fields shown on this screen will be bypassed and no entries
made.
‘Accept this screen? Y/N’, press ‘Y’ to accept the screen.
The PAS will return back to the Check In - Out screen ready for the next
patient.
5.3
Patient Transport
5.3.1
Nursing staff are responsible for identifying any patients that require
transport. Nursing staff must complete the appropriate transport (Form
AS3). The form must be passed to the outpatient reception staff.
5.3.2
When patients return to the reception to book a follow-up appointment
they must inform the reception staff that they require transport and hand
in the transport form.
5.3.3
When booking appointments for any patients requiring transport ensure
that the appointment is booked between 10.00am and 3.00pm. This is
due to the arrival and departure time of the patient transport at the
hospital.
5.3.4
Once the appointment has been made reception staff must write the
appointment date and time on the transport form, then give the:



middle copy to the patient with their appointment card,
bottom copy is kept by receptionist
yellow copy to the Transport Department
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Note: It is the responsibility of the Nursing staff or Consultant to
complete the Patient transport form.
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6
End of Day PAS Process
6.1
6.1.1
Completing End of Day
An end of day process is completed to ensure that there is a record of
whether each patient attended or Did Not Attend (DNA) their
appointment.
Note: On the PAS DNA’s are shown as ‘No show’.
Note: For all Outpatient Clinics the end of day process must be run.
6.1.2
Select menu ‘End of day’
Enter Resource - type in either the consultant/doctor resource number
or the name of the doctor/consultant.
Enter date or list - type in the date of the clinic that requires the end of
day process to be carried out, press return.
A list of patient’s that have been seen on that day will be displayed. If
patient outcomes show as either Pending or Auto, the outcome must be
amended as appropriate.
Select the patient that requires an outcome to be entered, press return.
If more that one patient has either pending or auto, all the patients can
be selected. The PAS will allow each patient to be dealt with.
Note: Care must be taken if more than one patient is selected to ensure
that the correct outcome is recorded. It is easy for the PAS to get
ahead so an incorrect outcome could be recorded a patient.
A message will be displayed ‘Enter edit (E), Cancel (C), Fill (F), or No
Show(N)’.
If the patient outcome needs to be entered, select ‘E’. If the patient
does not have an account number, select ‘E’ and go to section 6.2 End
of Day process for a patient with no account number (Page 29).
If the patient cancelled the appointment, select ‘C’. At the bottom of the
screen, select the reason the appointment was cancelled.
If the patient did not attend, select ‘N’, press return.
If the patient did attend, select ‘F’, press return.
The PAS will return to a screen showing that all the patients have had
their outcome recorded, press return.
If none of the patient’s outcome need to be changed, press return, a
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message will be displayed ‘Complete End of Day processing? Y/N’,
type ‘Y’, press return.
A message will be displayed ‘End of Day complete!’
Once the end of day process has been completed the clinic reception
area must be checked for case-notes. If any case-notes are remaining
the patient(s) will not have attended, see section 6.5 Patient that DNA
(Page 33).
6.1.3
All clinic/doctors lists must be forwarded to the medical records
supervisory/manager for the auditing purposes.
Note: If a receptionist is not present at the end of clinic, the nursing
staff must leave the clinic/doctors list, outstanding appointment slips,
patient transport requests and outpatient clinical coding sheets in an
envelope on the reception desk for collection. The receptionist will
collect the envelope the next day and update the PAS according to the
instructions left.
6.2
End of Day process for a patient with no account number
Type ‘E’, press return.
The patient’s appointment page is displayed.
Type ‘/4’ to go to New visit field.
A message will be displayed as ‘Is this a new Visit? Y/N’ type’N’, press
return.
The account number will be completed.
Type ’/’ to get to the bottom of the screen.
A message will be displayed ‘Accept this screen? Y/N’, press ‘Y’ to
accept the screen.
The PAS will return to the list of patient’s.
6.3
6.3.1
Discharing a patient that has had an outpatient
appointment
If the Consultant indicates that the patient does not require any further
appointments and does not need to be admitted, then the patient
episode will need to be discharged from the PAS. Ideally this will be
done as part of the End of Day procedure.
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Select ‘Appointment Enquiry’, press return.
Enter the patient’s case-note number.
Type ‘=’ to select all departments, press return.
Type ‘H’, for history, press return.
A message will be displayed ‘Accept this screen? Y/N’, type ‘Y’, press
return.
The PAS will display all the patient’s previous appointments. Select the
appointment for the consultant that needs to be discharged.
The next screen will display the appointment booking information.
Press return twice to get back to the main menu.
6.3.2
Select ‘OP Discharge Functions’, press return.
Select ‘Outpatient Discharge’, press return.
A message will be displayed ‘Enter acct #, ‘-‘ bed code, first char of
name’, type ‘=’, to bring the patient through, press enter.
The cursor will move to the field ‘Disposition’, select the reason the
patient is being discharged from the list at the bottom of the screen,
press return.
Disposition Date – type ’T’, to enter today’s date as the date the
patient has been discharged, press return.
Disposition Time – type ’T’, to enter the time, as the time the patient
has been discharged, press return.
Discharge Consultant/GP – at the bottom of the screen a message
will be displayed showing the consultant the patient is being discharged
from, press return to accept the consultant.
A message will be displayed ‘Accept this screen? Y/N’, type ‘Y’, press
return.
The next screen, none of the fields need to be completed, so press
return twice to display a message Accept Disposition? Y/N’, type ‘Y’,
press return.
A message will then be displayed ‘This patient has been
dispositioned!’
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6.4
Discharing a Outpatient episode
Select ‘General Enquiries’, press return.
Select ‘General Enquiries’, press return.
Select ‘MPI enquiry’, press return.
Enter the patient’s case-note number, press return.
Select ‘Visit Information’, press return.
The screen will display a list of all referrals for the patient, make a note
of the account number of the referral that requires to be closed.
Return to the main menu.
6.4.1
Select ‘Outpatient Functions’, press return.
Select ‘OP Discharge Functions’, press return.
Select ‘Outpatient Discharge Function’, press return.
A message will be displayed ‘Enter acct #, ‘-‘ bed code, first chars of
name’, type in the account number, press return.
The cursor will move to the field ‘Disposition’, select the reason the
patient is being discharged from the list at the bottom of the screen,
press return.
Disposition Date – type’T’, to enter today’s date as the date the patient
has been discharged, press return.
Disposition Time - type’T’, to enter the time, as the time the patient
has been discharged, press return.
Discharge Consultant/GP – at the bottom of the screen a message
will be displayed showing the consultant the patient is being discharged
from, press return to accept the consultant.
A message will be displayed ‘Accept this screen? Y/N’, type ‘Y’, press
return.
The next screen, none of the fields are completed, press return twice to
display a message Accept Disposition? Y/N’, type ‘Y’, press return.
A message will then be displayed ‘This patient has been
dispositioned!’
When a patient is discharged, Medical Secretaries are asked to check
that this has been recorded on the PAS.
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6.5
Patient Did Not Attend (DNA)
6.5.1
Before any patient is recorded as a DNA the PAS should be checked to
ensure that the appointment has not been cancelled at short notice. If
the appointment was cancelled, no action is required and the casenotes should be sent back to medical records.
6.5.2
If the appointment has not been cancelled at short notice, then the
patient DNA their appointment.
6.5.3
The reception copy of the clinic/doctors list must be marked DNA
against the patient that has not attended, this will be reinforced by the
fact that the case-notes will still be in the reception area.
6.5.4
The Clinical History Sheet must be stamped with the DNA stamp:
D.N.A
FURTHER
APPOINTMENT
DISCHARGE
6.5.5
It should be highlighted in the case-notes if this is the second time the
patient DNA their appointment.
6.5.6
The consultant the patient was booked to see must review the casenotes to decide whether another appointment is required.
6.5.7
The consultants must write in the patient’s case-notes whether the
patient is to be discharged or if another appointment must be offered.
This information must be passed to the Clinic Nurse who will liaise with
the clinic reception so the PAS can be updated.
Note: It is imperative that the PAS is updated to reflect the outcome of
the consultant’s decision on the patient’s DNA.
6.5.8
As a back up, Medical secretaries are asked to notify medial records
with
any action
regarding
DNA
patients
(contained
in
documentation/tapes returned from clinics) as soon as possible,
preferably within 48 hours of the clinic.
6.5.9
Decisions regarding discharge/future appointments must be made in
line with the DNA policy which (in brief) means that, apart from a reason
of clinical imperative, patients should be discharged back to their GP
and no further appointment made if they DNA an appointment twice.
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6.6
Outpatient Clinic Coding
6.6.1
Nurses, where appropriate, must pass all coding sheets to the reception
desk by putting them in the tray provided. All coding sheets are to be
marked clearly with the patients’ name, case-note number, consultant
and clinic date.
6.6.2
All Outpatient Coding Sheets must be forwarded to the Medical
Records Department.
6.6.3
Reception staff are required to clear their clinical coding procedure
sheets by the end of each week.
6.6.4
Any discrepancies are to be identified to the clinic nurse or Medical
Records supervisor.
Select menu ‘Outpatient Functions’, press return.
Select menu ‘Outpatient Procedure Coding’, press return.
Enter the patient’s case-note number, press return.
Press return again.
A message will be displayed ‘Enter History (H) or start date (Today)’,
type ‘H’, press return.
A message will be displayed ‘Accept this screen? Y/N’, type’Y’, press
return.
The screen will display a list of all outpatient appointments for the
patient.
Look for the date of the appointment that requires to be coded, select
the number of the appointment, press return.
Enter the code from the sheet, press return. Enter all the codes on the
sheet, then press ‘F12’.
A message will be displayed ‘Filed!’
The outpatient appointment for the patient has been coded.
On the coding sheet, if the patient has been discharged, the patient
must be discharged on the PAS.
Select menu ‘Appointment Enquiry’, press return.
Enter the patient’s case-note number, press return.
A message will be displayed ‘Enter History(H) or start date (Today)’,
type ‘H’, press return.
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A message will be displayed ‘Accept this screen? Y/N’, type’Y’, press
return.
Select the applicable appointment, press return twice.
Select menu ‘Consultant Discharge’, press return.
6.6.5
All the coding sheets are then filed by month of the date of the clinic in a
file in Medical Records.
6.6.6
If there is no appointment on the PAS for the patient, this must be
referred to an appropriate medical records member of staff.
6.6.7
When an Outpatient Clinical Coding sheet requires updating medical
records staff must complete the memo at (Appendix 7) and attach a
copy of the clinical coding sheet.
6.7
6.7.1
Sample checking
A number of regular sample checks must be completed on Outpatient
Clinics, these are:

DNA’s – the Information department will send regular reports to
Medical Record Managers highlighting DNA patients that have
not been booked another appointment or have been discharged.
Medical Record Managers must investigate and clear each
report.
Constant offenders must be reported to the
Outpatient/Medical Records Manager

DNA’s - SQL must be sent monthly to managers in Medical
Records on DNA patients that have not been rebooked or
discharged, it is the responsibility of managers to investigate and
clear these lists.
Random checks must be made in secretary offices for case-notes
of patients that DNA and enquiries made for constant offenders
as to why they have not actioned their DNA’s.

End of day - monthly reports are sent from the Information
Department to Medical Record managers. The report will identify
outpatient clinics that have outstanding ‘end of day’. Reception
staff are responsible for checking/updating missing information
on the PAS
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7
7.1.1
Case-notes
The following tasks must be carried out in strict line with the medical
records procedures:







Case-note numbering
Case-note structure
Making up case-notes for new patients
Filing of diagnostic test results
Transporting case-notes
Tracking patient case-notes
Temporary case-notes
8
Security and Confidentiality
8.1.1
Patients provide confidential information to staff whilst being treated by
the Trust. Patients have a right to expect that this information will be
and is kept confidential.
8.1.2
Staff must not disclose any confidential information unless as part of
their normal duties.
8.1.3
All staff must ensure that they keep all patient information secure and
confidential. The fact that the patient has an appointment at the
hospital is confidential.
8.1.4
DO NOT give medical records to patients or their relatives to take to
another department. In exceptional circumstances, if this is necessary,
the records should be put into a sealed envelope and the seal stamped
across it.
8.1.5
DO NOT to leave medical records unattended. It is the responsibility of
the person handling the case-notes to ensure that they are properly
tracked out of the library and that the tracking is updated if the casenotes are sent to another location.
8.1.6
Any records seen lying about in places such as sitting rooms, canteens
etc. should be collected immediately and returned to the library for filing
to ensure that they will be available when required.
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9
Contacts
Position
Name
Extension
Outpatient/Medical Records Manager
Anita Gurcan
6732
Outpatient Systems Manager
Barbara Rusbridge
6925
Team Leader for Appointment Contact
Debbie Trinder
Centre (East Surrey/Crawley)
6733
Appointment
and
Contact
Supervisor (East Surrey)
Centre
Claire Penfold
6734
Appointment
and
Supervisor (Crawley)
Centre
Doreen Flynn
3339
Medical Records Manager (East Surrey)
Stephanie Saunders
6723
Medical
Records
(Crawley/Horsham)
Janice Favier
3690
Data Quality Manager
Lyndee Peters
6520
Income Recovery Manager
Pam Ward
1702
Contact
Manager
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10
10.1
Appendices
Appendix 1 - Clinic Preparation Check List
Consultant: ______________________________________ Site: _________________________
Date & Time of Clinic: ______________________________________________________________
Clinic Preparation Checklist (Please initial in the box when the task has been completed)
Case-notes pulled
Casualty Cards/GP Referral letters collected/obtained
Case-notes tracked
Case-notes requested from other Trust sites
PID Sheet/Labels printed
Transport booked for patient
Comments: ____________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Outpatient Clinic Statistics
Number of patients on first doctors list ….………………………………………..
24 hours before Clinic - Number of patients on doctors list ……………………
Number of Patients removed from Clinic ………………………………..…….....
Number of patients added to the Clinic ………..……………………………..…..
At Start of Clinic - Number of missing case-notes ………………………………
At the end of Clinic - Number of cancelled patients …………………………….
At the end of Clinic – Number of patients that Did Not Attend …………………
At the end of Clinic – Number of Walk in Patients ………………………………
End of Day Completed ……………………………………………………………..
Comments ______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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10.2
Appendix 2 - 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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10.3
Appendix 3 - Patient Detail PAS Change Required Alert
Patient Detail Change Alert
Please circle the relevant detail change and ensure the amended details are recorded
on the front sheet inside the case-notes.
Name
Date of Birth
Address
Telephone Number
Next of Kin
GP
Date of change: _____________________________________________________________
Please attach to the front of the case-notes so Medical Records to update the PAS
Patient Detail Change Alert
Please circle the relevant detail change and ensure the amended details are recorded
on the front sheet inside the case-notes.
Name
Date of Birth
Address
Telephone Number
Next of Kin
GP
Date of change: _____________________________________________________________
Please attach to the front of the case-notes so Medical Records to update the PAS
Patient Detail Change Alert
Please circle the relevant detail change and ensure the amended details are recorded
on the front sheet inside the case-notes.
Name
Date of Birth
Address
Telephone Number
Next of Kin
GP
Date of change: _____________________________________________________________
Please attach to the front of the case-notes so Medical Records to update the PAS
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10.4
Appendix 4 – Clinic Cancellation/Reduction Form
Request for Clinic Cancellation/Reduction
From: _______________________________________________________________________
Date(s) of Clinic(s) to be Cancelled:
From: _________________
To: ______________
Date(s) of Clinic(s) to be Reduced:
From: _________________
To: ______________
Site:
Caterham
Crawley
Dorking
East Surrey GP Surgery
Horsham
Oxted
Reason:
Annual Leave
Special Leave
Study Leave
Sickness
Other, please specify
Cancel Sessions for:
Consultant
Staff Grade
Clinical Ass
Registrar
SHO
Other,
specify
please
Reduce the Number of patients to be seen:
From:
New Patient (NP)
Follow Up (FU)
To:
New Patient (NP)
Follow Up (FU)
Signed: _______________________________________
Date: _______________________
Please submit to the Outpatient & Medical Records Manager with copies to the system
supervisor at ESH and to the Operational Manager at Crawley & Horsham.
Date sent: ___________________________________________________________________
Date received:________________________________________________________________
Date Action: __________________________________________________________________
Note:
A minimum of six weeks notice must be given to ensure that the changes can be made
and patients informed. No guarantee can be given that changes will be implemented if
adequate notice is not given.
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10.5
Appendix 5 - Application for Additional GP’s on the PAS
To: PAS Manager, Maple House, East Surrey Hospital
From: _______________________________ Outpatient Department
Date: _______________________________________________________________
Please add the following GP to the PAS:
GP Name: ___________________________________________________________________
GP Address: _________________________________________________________________
GP Telephone Number: _______________________________________________________
Many thanks
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10.6
Appendix 6 - Patient Details Form
The information collected on this form will be used be entered onto the Trust’s Patient Administration
System. This system is used by Trust staff in the administration for your care and treatment. If you have
any queries, please do not hesitate to contact a member of staff.
Personal Details
NHS Number: ……………………………………….
Hospital Number: ……….…………..…….……
Surname: ………………………………...…..………………………………………………….…....…...…..
Forenames & Middle Name(s): .....………………..…………………………………...………...……….....
Marital Status: *Please delete as appropriate
* Married / Single / Divorced / Widowed
Sex: …………………………………….………..
Date of Birth: ………….…. \…. …….. \ ...…………
Religion: ..……………..…………………..….....
Place of Birth: ……………………………..…………
Occupation: ………….……….……..…..………
Permanent Address:…………………….…………………………………………………………....……….
………………………………………………..…………………………………………..…….……….……….
Post Code: ……………………………………………..
Home Phone Number: …….…….………….…
Mobile Phone Number: ……………………………….
Work Phone Number: ……………………..…...
Next of Kin Details
Next of Kin: …………………………………………
Relationship:………………….………….……..…
Address: …..………………………………………………………………………………………..….…………....
…………………………………………………………
Post Code: …..…………………..……...………...
Contact Number(s): …………………………………………………………………………………….………….
GP Details
GP: ………………………..…………………….………
GP Address: ………………….………………...
……………………………………………………………………………………………..………..……….
Have you resided in the UK for more than the past 12 months?
YES / NO
If No, what date did you arrive in the UK? ………………………………………………………………….
Have you visited the Trust before?
YES / NO
Do you have any special requirements/access needs whilst visiting the Trust, e.g. BSL
interpreter, assistance with mobility?…………………………...………………………………………
Official Use Only
Date of Admission: ……………………..
Time of Admission: ………………………………….………
Status of Patient: Waiting List / Booked / Planned / Emergency / Intermediate / Other: ….……….………
Admitting Consultant: ……………………………………..
Date:…………………………………………………….
Source of Admission: ……………...……
Time: ……………………………..……………...
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.
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10.7
Appendix 7 – Additional Code Request Form
MEMORANDUM
To:
Clinical Coding Manager
From:____________________________
Subject: Updating Clinical Coding Sheet(s)
Date: ____________________________
Please find ‘attached copies of Clinical Coding’ sheets that require:
New procedure codes to be added
Old procedure codes to be removed
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