PAS CLINICOM/PATIENT CENTRE POLICY
Version
1
Name of responsible (ratifying)
committee
Information Governance Steering Group
Date ratified
14th March 2012
Document Manager (job title)
ECR Development Service Manager
Date issued
25th May 2012
Review date
May 2014
Electronic location
PHT Intranet / Management Policies
Related Procedural Documents
Portsmouth Hospitals NHS Trust Data Quality Policy
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
CONTENTS
Reference guide
1. INTRODUCTION
2. PURPOSE
3. SCOPE
4. DEFINITIONS
5. DUTIES AND RESPONSIBILITIES
6. PROCEDURES
7. TRAINING REQUIREMENTS
8. MONITORING AND COMPLIANCE
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
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REFERENCE GUIDE
The guide below is a summary of the content of each required action.
1. The aim of this policy is to ensure all information recorded on a Patient record is relevant,
accurate and in a timely manner
2. Procedures for data capture and entry are followed at all times
3. Monitoring of data entry will be completed on a regular basis and all errors acted upon
accordingly
4. Training is undertaken to an appropriate level to gain the necessary skills and the available
tools to ensure PAS Data Quality is understood and maintained to an acceptable standard
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
1. INTRODUCTION
1.1
This Policy has been produced to ensure there is a full understanding of the process required
to record Patient data in a timely and accurate manner by all Clinical and Non-Clinical
members of staff.
1.2
The Policy will be broken down into sections with accompanying guidance for each Function
Set and to ensure full compliance with the Data Quality and Data Protection process.
2. PURPOSE
2.1
The key objective of this Policy is to ensure all PAS Users understand the Processes required
in keeping data held within PAS updated and secure at all Times
2.2
Procedures for data recording are followed and all Staff fully understand the implications and
potential risk to patient care and Data Protection with incorrect Data entry
2.3
All Staff fully understand the financial implications with incorrect Data entry and complete full
PAS training on the correct level of the modules required to obtain the tools available to support
their role
2.4
All staff understand Data entry must be completed in real time and are fully aware monitoring of
Data Quality is undertaken on a daily basis
3. SCOPE
3.1
This document is aimed to cover all levels of PAS to ensure the process for the individual
modules are carried out by Clinical and non Clinical staff in a timely manner
3.2
The importance of complete and accurate data collection is entered or updated in real time.
Data entry not collected and entered in real time has a financial implication for the Trust and will
impact on staff resource
3.3
This document supports the Portsmouth Hospitals NHS Trust Data Quality Policy and
Procedures and should be read in conjunction with this paper
4. DEFINITIONS
4.1
PAS – Patient Administration System used across Portsmouth Hospitals NHS Trust to record
all Patient activity in real time. Management of the system is in conjunction with our ICT
colleagues on the Isle of Wight.
4.2
ECR – Electronic Care Record is where all information relating to a Patient is held
electronically.
4.3
IPHIS – Island and Portsmouth Health ICT Services based at St James’ Hospital.
4.4
ICT – Information Communication Technology
4.5
NHS – category for National Health Service Patient’s receiving treatment
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
4.6
MIL – category for all Military Patient’s receiving treatment
4.7
XNH – a new Military ‘NHS’ category that has been mandated for certain Military Patient’s to
follow the NHS 18 week wait and not the normal 12 week wait for treatment
4.8
OSV – category for Overseas visitors receiving treatment
4.9
Masterfiles – the tables managed within PAS to ensure capture of all National and Local
definitions for measuring/reporting on required targets
5. DUTIES AND RESPONSIBILITIES
5.1
PAS Users are required to:
 Ensure the information collected for entry on to the PAS system is accurate and it is
imperative to be completed / updated in real time to support Patient confidentiality and reduce
risk to Patient care.
 It is the duty of the user to ensure they have gained the relevant information to complete data
entry in full.
 Data the User is unable to capture / complete must be highlighted by sending the appropriate
forms to the IPHIS Service Desk for investigation to ensure the PAS Masterfiles and / or
Patient record is updated accordingly and in a timely manner to reduce a possible breach of
Patient Confidentiality and a financial loss to the Trust.
 Accuracy of information by ensuring demographic data is checked and maintained every time
the Patient attends the Trust. The Patient must be the one to produce/supply the information
when asked and not the staff member inform the Patient what is already recorded.
 Report all anomalies to their Manager and / or the IPHIS Service desk to enable them to
inform the appropriate team for action to be taken.
5.2
User Managers’ responsibilities
 All Managers must ensure staff can be released to attend essential PAS training courses to
obtain the tools they require to complete their role.
 When the need to audit activity is carried out, any User found to be sharing passwords will
have their access removed while an investigation is completed. The Manager will be notified
of the breach and their support for action taken to remove the User access will be required
and to raise awareness as this will impact on the performance of the individual within the
department.
 Ensure that all required changes / additions to PAS Masterfiles are reported to the IPHIS
Service Desk by completing the appropriate forms to ensure the system is updated
accordingly to reflect the need.
6. PROCEDURES
6.1
Data Quality for an electronic system relies on accurate recording for the reporting of the
information collected and has a number of ‘umbrellas’ and ways in which it can be measured.
Understanding and following the procedures set down by the Trust will be imperative and action
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
taken if not adhered to. The main emphasis is to aid in the care of the Patient and to support
the financial income to the Trust.
6.2
There are National requirements set for Data Quality standards and inclusion is the population
of the NHS number. All systems must meet 95% standard of whole Patient Index population.
6.3
Software updates and enhancements are implemented within PAS twice a year and 2 hours
downtime for uploading is a necessity. Planned downtime will be managed by Change
Management within IPHIS. Notification will be issued 5 working days prior to the system being
taken off line. Users will be notified of expected changes and enhancements to the system via
Flyers produced by the ECR Development Team.
6.4
A report is produced daily from the Chimera Data Warehouse to locate the duplicate
registrations. The offending User ID is recorded and immediate action taken for resolution to
the Patient record and assist in the reduction of risk to Patient Care.
6.5
A report of the findings / outcomes per User will be produced on a monthly basis and passed to
the IPHIS ICT Training Dept. The Trainer will contact the user responsible for creating three or
more duplicate registrations in one month. 1-1 refresher training for Registration processes will
be completed to ensure the User is competent to continue using the system.
6.6
When a User continues non compliance of the rules for registration, the Manager will
accompany the ICT Trainer in a competent test for their staff member. If the user is unable to
continue to use the system without causing risk to patient care, their access will be removed
until the Trainer is confident they are competent to regain use of the system.
6.7
A patient registered on a system has many aspects of information and is imperative it is
accurately collected and recorded. Initial search procedures are vital to reduce the possible
raising of a duplicate record and thus impact on the care of the Patient. All Patient demographic
details must be checked on every attendance to the Hospital and PAS must be updated before
the patient has left the department.
 Spelling of Surname and Forename – essential to be correct to reduce duplicate registrations
or selecting the incorrect Patient record and impact on patient care with incomplete
information. Full search procedures must be carried out for every Patient each time they
attend or are referred for consultation
 Correct NHS Number - used as prime identifier for locating a patient record. If not included at
the time of referral or attendance, SCR the National Summary Care Record system should be
used to locate the missing data
 Correct Date of Birth – imperative when selecting from a Patient list
 Military Number – currently replaces NHS number for Military staff and supports the need to
ensure the correct Category is selected and entered on each episode for a Military Patient
and should be MIL or XNH and not NHS
 Gender – must only be changed if entered incorrectly or when the Consultant confirms
complete transition has taken place
 Address and Postal Address - must be updated on PAS immediately the notification has been
received for Data Protection purposes and to support the reduction of Patient DNA’s
 Post Code – imperative it is correct and will impact on the Trust Financial billing and income
and assist in Patient Data Protection
 Home Phone Number – Must be entered correctly to support text messaging
 Mobile Number
and for ease of contact with the Patient and Patient
 Work Number
)Data Protection
 GP details - imperative it is correct and will impact on the Trust Financial income and Patient
Data Protection. All attempts at locating the GP details must be made before the final
selection of Not Know, Not Registered or Not Given are entered on the Patient record.
 GDP details - imperative it is correct for billing and Patient Data Protection purposes
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
Next of Kin – incorrect details impact on Data Protection and ease of contact
Religion – important for a Patient who will require a visit from the Chaplains
Ethnic Category – will support Patient’s with dietary needs
Occupation – correct recording can support in the treatment of the patient if they are working
in an ‘at risk’ environment
 The death of a Patient must be recorded immediately upon notification to ensure DNA letters,
future Appointment reminders are not sent out to further upset a relative/s and ensure the
cancellation of pre-booked transport is completed
 Overseas Visitors - can lead to a huge loss of finance to the Trust if recorded incorrectly and
must be reported to the Manager if in doubt of correct selection and entry
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6.8
The Emergency Department register the Patient on the PAS system the moment they arrive in
the Department to ensure real time Attendance and location is available at all times. All steps
must be recorded in real time to enable ED Manager’s, ED staff, the Chief Operating Officer
and Duty Manager’s to be able to see at a glance exactly how many Patient’s are currently in
the department, the wait times and their location.
 The Reception staff will be responsible for recording the attendance arrival date and time
stamp in real time and for the production of the Casualty Card
 Triage assessment will be completed by a trained clinical staff member and recorded on the
Patient record along with the location the Patient will be seen within 15 minutes of the
Patient’s arrival
 Tracking of the Patient through the department will be completed by the Clinical staff in real
time to ensure location, status and treatment of a patient is available at all times
 Discharge of the Patient from the Department must be in real time and is the responsibility of
the last Clinical member of staff in the ED Team to treat the patient or by the Reception staff
upon request
 The Coding of the Patient attendance and production of the GP letter is the responsibility of
the Reception staff to ensure all activity and treatment is recorded for billing and income
purposes
6.9
Casenote Tracking is a mandatory process supported by Portsmouth Hospitals NHS Trust
Senior Management Team. The Health Records Library Services are responsible for storing all
Casenote folders in a central suppository when not in use. PAS will support the electronic
Management of the Casenotes. The movement of Casenotes is the responsibility of all Clinical
and non-Clinical Users who handle them and tracking must be done in a timely manner to
ensure Patient care is not placed at risk due to lack of information and location being available.
 Casenote Loan Enquiry will allow a User to view where the Casenotes can be located
 Casenote Borrower will allow a User to view all sets of casenotes currently in that location
 Loan Casenote will allow the User to record the Borrower who has requested the Casenotes
and will include the option to view the loan history
 Transfer Casenotes is to be used when the Casenotes move from department to department
and when Casenotes are returned to the ARCHQ in Health Records Library
 Return Casenotes is for use only to the Health Records Library Staff for returning and placing
them on the shelf in the holding Library
 It is the responsibility of the sending dept. to update PAS with the new location at all times
6.10 Accurate recording of Episodic Activity is imperative to the Trust and will impose an impact to
loss of revenue if not completed in a timely manner. Outpatient, Inpatient, Waiting List and Preadmission all fall into this category.
6.11 18wk RTT targets have impacted on the Quality of Data due to the complexity and the User
understanding of the functionality.
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
6.12 Choose and Book the GP direct electronic Outpatient Appointment Booking System is the main
offender for the constant duplications created. These are resolved on a daily basis by the ECR
Data Quality team within ICT.
6.13 The Outpatient Module is the location of where the Clinics are built and managed to the
Consultants requirement.
 All Patient details must be checked and updated at the time of manual referral entry
 GP details – PAS must be updated when the referring GP is not the Patient’s registered GP
 Specialty – correct selection is imperative 300 General Medicine is for use only in MAU and
100 General Surgery is for use only in SAU and is not to be used outside of these Ward
environments
 Category – correct selection is imperative to the Trust financial income e.g. NHS, MIL, OSV
etc
 Dates – correct date and time stamp is essential for billing and income purposes
 Appointment Booking – Patient Choice with earliest reasonable offer details to be completed
to support the Trust with a Patient ‘decline of an appointment offer’ process
 18 week RTT – all referrals received via an Outpatient Dept will start a Pathway with correct
completion of screens with the exception of 2 week wait suspected Cancer Patients with the
processes of this owned and managed by the PHT 18 wk RTT Team
 Choose and Book – the process above has been pre-set within the system to ensure capture
of all these aspects
6.14 The Admission Module is where all Activity for an Inpatient stay is recorded
and Managed.
 All Patient details must be checked at the time of arrival to the Ward
 Admission – a Patient admitted to a Ward must be completed on PAS in real time and no
later than 15 minutes of their arrival
 Specialty – correct selection is imperative 300 General Medicine is MAU only and 100
Surgical Admission is SAU only and are not to be used outside of these Ward environments
 Category – correct selection is imperative to the Trust financial income e.g. NHS and MIL
 Dates – correct date and time stamp is essential for billing and income purposes
 Overseas Visitors - can lead to a huge loss of finance to the Trust if incorrect and must be
reported to the Manager if in doubt of correct selection and entry
 Transfer – the sending Ward is responsible for the completion on PAS of the Transfer details
the moment the patient leaves the Ward for Bed Occupancy to assist with Free Bed Enquiry,
the receiving Ward are responsible to ensure the details of the transfer are correct
 Discharge – a Patient at the time of discharge must be recorded in real time
 Discharge Lounge – a Patient who is sent to the Discharge Lounge(to await Transport,
Pharmacy medication etc.) from a Ward is a Transfer and not a Discharge
 Discharge Lounge – it is the responsibility of the staff in the Discharge lounge to record the
Patient discharge and correct destination details as they leave the Hospital
6.15 The Ward Attender module is where the Activity is recorded for a Patient who will present on
the Ward either as a Planned or Unplanned attendee and will receive treatment/consultation
from a Doctor or a Nurse as an Outpatient and without being admitted to a bed. A Patient who
is a regular Ward Attender must be recorded as an Attendee and Discharged at every visit.
 All Patient details must be checked at the time of arrival to the Ward
 Attendance – the Ward Attendance must be recorded in real time to collect Ward occupancy
(not Bed occupancy) in cases of Fire, Patient location, infection etc. and for ensuring no
financial loss to the Trust
 Discharge - a Patient at the time of discharge must be recorded on PAS as they leave the
Ward and if appropriate given another appointment to return to the Ward
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014
6.16 The Waiting List + Pre-Admission module is for the recording and Management of Patient’s
who are waiting to come into Hospital to receive Treatment.
 All Patient details must be checked at the time of decision/receipt of the ‘To Come In’ request
 Waiting List – a Patient is added to an elective Waiting List to await a date to come in for
Treatment
 Planned Waiting List – a Patient is added to an elective Planned List and will be informed they
will come in for treatment within a period of time e.g. within 2 weeks
 Booked Waiting List – a Patient is added to an elective Booked list and will be issued with
their date to come in
 Specialty – correct selection is imperative 300 is MAU only and 100 SAU only and are not to
be used outside of these Ward environments
 Category – correct selection is imperative to the Trust financial income e.g. NHS and MIL
 Dates – correct date and time stamp is essential for billing and income purposes
 18 week RTT – all referrals received via an Outpatient Dept will start a Pathway with correct
completion of screens with the exception of 2 week wait suspected Cancer Patients and it is
imperative the Pathway is updated accordingly
 Overseas Visitors - can lead to a huge loss of finance to the Trust if incorrect and must be
reported to the Manager if in doubt of correct selection and entry
7. TRAINING REQUIREMENTS
7.1
Department and Ward Managers are responsible for ensuring staff will receive appropriate
training in the Modules they require to fulfill their role.
7.2
It is the Manager’s responsibility to arrange the Training to the level of access the User will
require and to ensure the release of the staff member to attend the relevant courses to enable
access to the PAS system.
7.3
Staff who share their Username and Password to the PAS system are breaking the rules and
regulations of the Data Protection Act and Trust Policy and if found to be doing this their access
will be removed immediately whilst investigation takes is undertaken.
All PAS Training is hosted by the IPHIS, ICT Training Department, First Floor,
Victoria House, QAH. x5867.
8. MONITORING AND COMPLIANCE
8.1
Monitoring of compliance with this policy is undertaken by the ECR Data Quality Team who
focuses on key elements of Data and run audits when required on the Users concerned and
work in conjunction with the ICT Training Department.
8.2
A bi weekly IQA report is produced from the Chimera Data Warehouse and is available to notify
interested customers of the current status of the PAS system Data Quality.
8.3
All breaches of this Policy will be fully investigated and logged on the ICT Service Desk System
and reported to the ICT Security Team.
Pas Data Quality Policy and Procedures
Version 1.0
Issued January 2012
Review Date: January 2014