Patient Administration System

Patient Master Index(PMI)

Revision Date: Version 4.5July 2011

PMI Basic – v 4.5

ICT Training First Floor, Victoria HouseQueen Alexandra Hospital

Cosham PO6 3LYTel: 023 9228 6000 ext: 5867

Email: ICT.Training@iphis.nhs.ukWebsite: www.training.iphis.nhs.uk

ICT TRAINING has made every effort to ensure that the material in this manual was correct at the time of publication but cannot be held responsible for any errors or inaccuracies.  ICT TRAINING reserves the right to change or replace information contained in the manual without notice. For the most up to date version please refer to the ICT Training website.  All references made to patient records are fictitious for the purpose of training only.

CONTENTS

1. GENERAL COURSE INFORMATION..............................................................................12. INFORMATION GOVERNANCE....................................................................................2

2.1. What can you do to make Information Governance a success?.......................23. CONFIRMATION OF DETAILS PROCEDURES................................................................44. KEYBOARD LAYOUT...................................................................................................5

4.1. Primary keys and their function.......................................................................54.2. Function Keys - ‘F’ Key Set...............................................................................6

5. HOW TO LOG ON.......................................................................................................75.1. Logging on for the first time............................................................................75.2. Subsequent logging on....................................................................................8

6. CROSS SITE ACCESS..................................................................................................96.1. How to change hospital code...........................................................................9

7. PMI LIST <LIS>........................................................................................................107.1. Basic guide....................................................................................................10

8. SEARCH PROCEDURES............................................................................................138.1. Recommended search procedure..................................................................138.2. Other search methods...................................................................................138.3. Help list..........................................................................................................14

9. PATIENT EPISODE ENQUIRY <EPI>..........................................................................1510. APPOINTMENT ENQUIRY <APE>..............................................................................1611. DOCUMENT PRINT <DP>.........................................................................................1712. DISTRICT WIDE INPATIENT NAME ENQUIRY <NID>..................................................1813. INPATIENT NAME ENQUIRY < NI >...........................................................................2014. INPATIENT LOCATION LISTS <IPL>..........................................................................2115. PATIENT PATHWAY VIEWS <VPP> <VPA>...............................................................2216. GP AND DENTIST ADDRESS LABELS <GPL> AND <GDA>.......................................2417. CASENOTE NUMBER LOCATION EXPLANATION LIST.................................................2518. EPISODE STATUS DESCRIPTION...............................................................................2719. SPECIALITY CODE LIST.............................................................................................2820. PATIENT ADMINISTRATION SYSTEM (PAS) DEFINITIONS...........................................29

20.1. Introduction...................................................................................................2920.2. Description of episode types..........................................................................2920.3. List of definitions............................................................................................30

PMI Basic – v 4.5

21. FAULT REPORTING...................................................................................................3421.1. ICT Service Desk............................................................................................3421.2. Out of office hours.........................................................................................3421.3. ICT Training....................................................................................................35

22. HELP WITH USING PAS.............................................................................................3523. ICT TRAINING CANDIDATE APPEALS PROCEDURE....................................................3624. Version Control/Log.................................................................................................37

PMI Basic – v 4.5

Patient Administration System (P.A.S) Course

1. GENERAL COURSE INFORMATION

_______________________________________________________________________

COURSE TITLE PMI BASIC – LEVEL 0METHOD OF TRAINING WorkshopDURATION Recommended 2 hoursPRE-REQUISITES None, although keyboard skills advisable

_______________________________________________________________________

ABOUT THE COURSEThe PMI Record holds general demographic details about a patient and an outline of any episodes of care occurring at hospitals within the Portsmouth/IOW area and Community Contacts/Services. The course will enable students to search and identify specific patients and information.

_______________________________________________________________________

SUITABLE FORAll Staff – Clerical & Clinical

_______________________________________________________________________

OBJECTIVES

This course will enable the student to:

1. State their personal responsibilities for Data Protection and Caldicott Principles.

2. Log on and off of the PAS system.

3. Find and select a Patient.

4. Identify specific information, e.g. GP, Casenote Number, etc.

5. Select specific episodes to identify information.

6. View lists of current Inpatients.

7. View lists of individual outpatient appointments.

8. Select and Print Documents.

PMI Basic – v 4.5 1

2. INFORMATION GOVERNANCE

Information Governance (IG) sits alongside the other governance initiatives of clinical, research and corporate governance. Information Governance is to do with the way the NHS handles information about patients/clients and employees, in particular, personal and sensitive information. It provides a framework to bring together all of the requirements, standards and best practice that apply to the handling of personal information.

Information Governance includes the following standards and requirements:

Information Quality Assurance NHS Codes of Conduct:

o Confidentialityo Records Managemento Information Security

The Data Protection Act (1998) The Freedom of Information Act (2000) Caldicott Report (1997)

2.1. What can you do to make Information Governance a success?

2.1.1. Keep personal information secureEnsure confidential information is not unlawfully or inappropriately accessed. Comply with the Trust ICT Security Policy, Confidentiality Code of Conduct and other IG policies. There are basic best practices, such as:

Do not share your password with others Ensure you "log out" once you have finished using the computer Do not leave manual records unattended Lock rooms and cupboards where personal information is stored Ensure information is exchanged in a secure way (e.g. encrypted e-mails, secure postal or

fax methods)2.1.2. Keep personal information confidentialOnly disclose personal information to those who legitimately need to know to carry out their role. Do not discuss personal information about your patients/clients/staff in corridors, lifts or the canteen or other public or non-private areas.2.1.3. Ensure that the information you use is obtained fairlyInform patients/clients of the reason their information is being collected. Organisational compliance with the Data Protection Act depends on employees acting in accordance with the law. The Act states information is obtained lawfully and fairly if individuals are informed of the reason their information is required, what will generally be done with that information and who the information is likely to be shared with. 2.1.4. Make sure the information you use is accurateCheck personal information with the patient. Information quality is an important part of IG. There is little point putting procedures in place to protect personal information if the information is inaccurate.

PMI Basic – v 4.5 2

Further information can be accessed through the Trust Intranet:

Information Governance (Departments sections), and Management Policies (Policies section)

2.1.5. Only use information for the purpose for which it was givenUse the information in an ethical way. Personal information which was given for one purpose e.g.hospital treatment, should not be used for a totally separate purpose e.g. research, unless the patient consents to the new purpose.2.1.6. Share personal information appropriately and lawfullyObtain patient consent before sharing their information with others e.g. referral to another agency such as, social services.2.1.7. Comply with the lawThe Trust has policies and procedures in place which comply with the law and do not breach patient/client rights. If you comply with these policies and procedures you are unlikely to break the law.

For further Information Governance training refer to:http://www.igte-learning.connectingforhealth.nhs.uk/igte/index.cfm

Written by PHT Information Governance Manager, Sept 2010

PMI Basic – v 4.5 3

3. CONFIRMATION OF DETAILS PROCEDURES

To ensure that the Patient Administration System (PAS) contains up to date particulars of all patients being treated, staff must verify with patients their personal details. This should be undertaken when the patient is arriving at the hospital on admission or when attending for an outpatient clinic or other types of appointment.

The types of details we must verify are those within the Patient Master Index (PMI) function within PAS and covers the following items:

Patient Forename, Surname and Title Date of Birth NHS Number (If not one shown on screen) Address and Postcode Telephone Number – Home and Work numbers Name and Practice Address of GP Religion Marital Status Next of Kin Ethnic Group Military No (If applicable)

By checking the above details with the patient, we are ensuring the following:

* PAS contains the latest details for all our patients.* Mistakes or “old” details can be amended.* Information relating to the patient’s well-being, such as Religion and Ethnic Group, can be

used in patient care.* Emergency contact details for relatives are up to date.

In some circumstances it will be difficult to verify the details highlighted above as the patient may not be coherent at time of arrival (eg emergency admission, A&E, etc). However, it is important that at the earliest opportunity, the details are verified and amended accordingly.

Important – If details are amended * , please remember to print a new set of labels, remove and destroy any incorrect labels from casenotes. We must not retain any labels that do not contain current details.

Many thanks for your cooperation.

Prepared by: ICT Information Manager Issued: January 2003Reviewed: July 2011Version No: V1.2

* To amend patient details you will need to have access to PMI at level 1. Please book the course PMI Add and Revise. In the meantime make sure you ask a colleague with access to amend the patient record.

PMI Basic – v 4.5 4

4. KEYBOARD LAYOUT

4.1. Primary keys and their function

1. RETURN or ENTERMust be pressed at the end of each entry you make. It tells the computer that you have finished typing the prompted keystroke.

2. BACKSPACEUsed to delete the last character typed. Repeated pressing deletes characters to the left. This key can only be used for correcting errors BEFORE pressing the RETURN/ENTER key.

3. DELETE (DEL)Can be used as a BACKSPACE key. Can also be used in conjunction with arrow keys to re-enter a word to delete an individual character.

4. ARROW KEYSCan be used to move selection highlight/cursor around the screen. They allow movement up, down, (left and right on menu only). Can also be used to re-enter a word, and to amend if necessary.

5. SHIFTTo produce the upper symbol of dual character keys and upper case letter characters.

6. CAPS LOCKTo produce upper case alphabetical characters only without having to use the shift key. Does not affect the upper symbol keys. Pressing key ON will display light on right hand side of keyboard or display words CAPS LOCK in corner of screen, dependant on the type of computer terminal being used. Pressing key again will release CAPS LOCK.

7. PAGE UP and PAGE DOWNUsed to move back and forward on lists, which extend further than the screen space allows. E.g. If display prompts ‘do you want NEXT page’, use the page down key, to go back again use the page up key.

8. NUMERIC KEYPADNumeric pad to right of keyboard. May be used instead of the number keys above the letter keys. Pressing NUMBER LOCK (NUM LOCK) key will display light on right hand side of keyboard above the numeric pad. Pressing key again will release NUMBER LOCK.

PMI Basic – v 4.5 5

IMPORTANT NOTE:

CAPS LOCK MUST BE OFF WHEN LOGGING ON TO THE SYSTEM.CAPS LOCK MUST BE ON ONCE YOU ARE LOGGED IN.

4.2. Function Keys - ‘F’ Key Set

“F” key functions could be different depending on the program being used.Use of ‘F’ keys within P.A.S. (Patient Administration System)

F1 = Exit

F2 = Delete Field

F3 = Go To First

F4 = Go To Field

F5 = Go To Page

F6 = Previous Field

NB: Also used to change function set and change hospital code.

F7 = View (Refreshes screen)

F8 = HELP (explain and advice)

F9 = SUPERHELP (selection lists)

F11 = Multi-Select (Allows selection of more than one item in a list, certain functions only)

PMI Basic – v 4.5 6

5. HOW TO LOG ON

Upon completion of training and ensuring that you are confident and competent in the use of the system, the trainer will send an authorisation form to the PAS Applications team asking them to set up your account.

You will then receive notification from them giving you your ‘USERNAME’ and instructions on how to complete the initial log on.

If you have not received these instructions after 5 working days following the course, please contact the ICT Service Desk see contact numbers on page 34.

5.1. Logging on for the first timeDue to the variation of computer equipment being used within the Trusts log-in procedures can differ between areas. Check with your area what yours entails.

NOTE: If using a PC or Thin Client you must have an NT account set up. Ask your manager to ensure that this is arranged.

Having selected PAS, at the prompt:

Login: Type in ‘prd’ <Return>

When you are asked for the ‘USERNAME’, type in the PAS ‘Username’ you have been allocated by the Applications team, (usually your surname and initial or combinations of them), and then press ‘Enter’

At the prompt:

Password: Type in the password allocated to you by ICT Service Desk

The screen will then indicate that this has expired and ask you to type in a new password. This is where you type in the password that is only for your use and MUST NOT be shared with anyone, (see ‘Information Governance’ on Page 2). You will then be asked to type it in again as verification.

Passwords can be a combination of letters and numbers but must not be less than 6 or exceed 12 characters.

If you have been given access to record information for more than one site you will then be asked to enter the Hospital Code you wish to record for , e.g. QAH, SMH.

PMI Basic – v 4.5 7

5.2. Subsequent logging onFor subsequent log-ons at the following prompts you will need to enter:

Log in: prd (if required) <Return>

Username: e.g. bloggsj <Return>

Password: _ _ _ _ _ _ _ _ _ <Return>

Hospital: (as appropriate)

Your password lasts for 90 days; you will be warned that it is running out so you have time to think of a new one.

If you have only been given access to PMI Basic, upon login, you will be presented with the following screen:-

NOTE: If you forget your password or need to reset it, please contact ICT Helpdesk; see page 39.

PMI Basic – v 4.5 8

6. CROSS SITE ACCESS

When you first log on you may be asked to enter a Hospital Code - type in either SMH or QAH (or other hospital code) whichever is appropriate for the activity you are dealing with / recording.

You can also use the ‘superhelp’ key (F9) to see a list of hospital codes that you have been given access to, and then select the code from this list.

If you have computer access to more than one site e.g.: SMH & QAH (remember RHH is recorded at QAH), you can move from one to the other without completely logging out of the system.

NOTE: When you are working in a selected function, the hospital you are logged in as will be displayed in the top right hand corner of the screen.

6.1. How to change hospital code

Press F1 until you are on a menu screen.

Press F6 until you are asked for the Hospital Code, enter the code required and you will get the first function set Menu, e.g. PMI, if this is not the function set required press F6 and select as usual.

Remember - you could have different access at each site. If the menus look different e.g. more or less functions, it could be that you have logged onto the wrong hospital.

If you have selected a particular patient to record activity against and then change hospitals you can still use the quick Recall facility by typing ‘L’ for Last Patient Selected.

PMI Basic – v 4.5 9

7. PMI LIST <LIS>

The function <LIS> is the means to establish if a patient has had past contact with any of the Portsmouth Hospitals, the Community Services or the Isle of Wight. If they have then all or part details will be found on the PMI (Patient Master Index), searches can be made using various combinations of patient demographic information, i.e. surname and forename initial, date of birth or approximate age and sex, or any combination. If no matches are found, a list of similar sounding names may be made available to you. To ensure entries are not duplicated, use casenote number only as a last resort.

7.1. Basic guide1. Log on in the usual manner.

2. Select function <LIS> and press <RETURN>.

3. To search for the patient always start by using the recommended SEARCH PROCEDURE of surname, forename initial, date of birth, sex (see notes overleaf for other help/suggestions).

Press <RETURN>. A list of possible matches will be displayed, e.g.

Definitions of some of the symbols you may see in the Matching Patient Records screen:

# indicates a surname the patient was previously known under.& indicates the preferred name to address the patient if different to their forename. * indicates the patient is recorded as deceased.

PMI Basic – v 4.5 10

4. Select correct patient from list by entering the appropriate Sequence Number found on the left hand side of the screen. Press <RETURN>. The patient’s basic details will be displayed. Check that they are correct and that you have the correct patient.

NOTE: You must select the sequence number, even if only one patient is displayed on the screen.

5. For other details select from the taskbar at the bottom of the screen:

1. DETAILS 1 - Displays General Practitioner (GP) Details, Next of Kin, Religion, Marital Status, NHS Number etc.

2. DETAILS 2 – Displays General Dental Practitioner (GDP) Details, Ethnic Origin etc.

3. CASENOTES - Displays casenote number(s), base location of notes and status (current or withdrawn).

4. EPISODES - Displays all previous and current activity, attendances and episodes of care; eg: inpatient, outpatient and service group events, in reverse chronological order (most recent dates are at the TOP of the list).

Press relevant number for information required, then <RETURN>. Further details will be displayed.

6. Press F1 to exit <LIS>, or <Enter> to return to the Search screen.

PLEASE ENSURE THAT YOU READ THE NEXT PAGE.

PMI Basic – v 4.5 11

8. SEARCH PROCEDURES

8.1. Recommended search procedureThe first search for a patient should always be by following the ‘RECOMMENDED SEARCH PROCEDURE’:

SURNAME, FORENAME (Initial only), DATE OF BIRTH & SEX

By using this method up to 90% of patients can be identified on the PMI.

8.2. Other search methodsIf only NAME AND DATE OF BIRTH available, press <RETURN> until the cursor reaches the Surname field. Type in surname <RETURN>, forename initial <RETURN>, date of birth <RETURN> (past postcode field) to end of screen.

NOTE: Remember when using a date of birth the +/- field will only search on the year of birth not on the day or month. The default in the +/- field is 3 years, overtype to change (0-9). You could convert the DOB to an approximate age. This will search on all dates within the range.

If NAME ONLY available, press <RETURN> until the cursor reaches the Surname field. Type in surname and forename initial.

THINK: Use various combinations of information to ensure you do a full search of the PMI, and identify the correct patient. If a patient has a preferred name different to their forename and it has been recorded on their PMI record you will still be able to find the patient using their preferred name in the forename field.

NOTE: Do not search using the postcode even if this is combined with other details.

CASENOTE NUMBER ONLY - type in the Casenote Number in the relevant field, press <RETURN>.

REMEMBER: if searching by casenote number the system will find anything under this number, even if the casenote number has been withdrawn from use. You must access the ‘casenote’ selection of the patient record to check current ‘live’ number is used. Also, if searching by casenote number this will not show possible ‘double’ registrations, therefore search by casenote number should only be used in special circumstances.

PAS NUMBER ONLY - type in the PAS Number in the relevant field, press <RETURN>.

NHS NUMBER ONLY – type in the NHS Number in the relevant field, press <RETURN>.

MILITARY NUMBER ONLY – type in the Military Number in the relevant field, press <RETURN>.

PMI Basic – v 4.5 12

8.3. Help listWhen searching for a patient if you cannot find them using the ‘Recommended Search Procedure’ remember to try various combinations of information.

Recommended Procedure:

Surname, Forename Initial, Date of Birth and Sex.

Subsequent Methods to Try:

Remove forename initial Remove the DOB Remove the sex Convert the DOB into an age Adjust the years +/- box (0-9) Remember only use the initial of the forename Use less letters (shorten) the surname Use the swap forename and surname option Use the similar sounding names option

1. Part surname - e.g. LEW for LEWKOWICZ.2. Double-barrelled name - could be reversed, e.g. Warwick-Brown, Brown-Warwick.3. Similar sounding names - e.g. Walters - Waters, Shepherd - Sheppard.4. Forenames such as Kathryn, Katherine or Catherine. Is initial entered correctly?5. Could Forename and Surname be reversed - e.g. Thomas Paul, Paul Thomas6. Male and female versions of names such as Lesley / Leslie, Frances / Francis, Lee / Leigh /

Lea. If the name has been spelt wrongly, another user may have amended the sex field to try to match the name, so you could try leaving the sex field blank. (F2 to delete field).

Do not assume sex by forename, e.g. Kim, Charlie, Lee could be male or female.

7. Children could be registered as M-I (Male Infant) F-I (Female Infant) if they were not named at birth, or forename could have been changed after birth registration.

8. Child could have a different surname from parent.9. Remember the Age +/- search only checks either side of the YEAR of the date of birth.

Therefore, try checking on age only search. (Default is 3 years).

ALWAYS BE AWARE OF THE SEARCH OPTIONS YOU HAVE.EVERY EFFORT MUST BE MADE TO AVOID DUPLICATED ENTRIES.

REMEMBER: A patient’s casenotes on a shelf in Health Records does not help in the care of the patient - so search thoroughly.

PMI Basic – v 4.5 13

9. PATIENT EPISODE ENQUIRY <EPI>

This function will make available to you detailed episode information on:-

a) INPATIENT ADMISSIONSb) WAITING LIST EPISODES.c) OUTPATIENT REFERRALS.d) WARD ATTENDER EPISODES.e) ACCIDENT & EMERGENCY ATTENDANCES - front screen onlyf) SERVICE GROUP REFERRALS

1. Log on in the usual manner.

2. Search for patient in the <LIS> function. Select patient using sequence number (on left side of screen). Press F1 to exit back to the menu.

3. Select function <EPI> from the menu and press <Return>. Type ‘L’ (for last patient selected) in any of the top 5 fields, this will bring the patient selected in <LIS> to the Episode Enquiry screen, eg:

4. For more detailed information of any episode, select your episode by sequence number, press <RETURN> and further episodic information will be displayed.

5. If the patient has not had any episodes, the screen will provide the message:

NO RELATED EPISODES FOUND

6. Press F1 to exit <EPI>.PLEASE SEE PAGE 30 FOR EPISODE STATUS DESCRIPTION LIST

PMI Basic – v 4.5 14

10. APPOINTMENT ENQUIRY <APE>

Appointment Enquiry will display ALL the patient’s Outpatient and Service Group appointment and waiting list activity. Waiting List activity will be displayed at the top of the list followed by Appointments. The list is displayed in date order with the most recent event at the top of the list.

For more detailed information select the appointment by using the sequence number or by moving

the highlight bar to the appropriate appointment and press <Return>.

NOTE: You will only be able to select those appointments for the speciality for which you have booking access. If selected, the appointment details will be viewed on the screen e.g. transport details, comments etc.

PMI Basic – v 4.5 15

11. DOCUMENT PRINT <DP>

This function is for printing a variety of labels, letters, etc.

1. Log on in the usual manner.

2. Search for patient using LIS function. Select patient.

3. Select Function <DP>. Type ‘L’ for last patient selected.

4. Screen displays episodes to choose if appropriate.

5. Either select Episode or press <RETURN> until the Select Document prompt appears.

6. Select Document: Press Superhelp - F9 - and select document required, e.g.:

LAB Kyocera LabelsBARL Barcode LabelsPSS Provider Spell Summary/Summary SheetPID Patient Identification Sheet

Casenote Number: After selection of document the system may request the ‘Casenote Number’, press F9 and select as appropriate.

Destination: Enter printer name or number.

Copies: Enter number of copies required.

REMEMBER if needing labels - 1 copy = 2 Barcode Labels14 Address Labels.

Enter: YES / NO.

PMI Basic – v 4.5 16

12. DISTRICT WIDE INPATIENT NAME ENQUIRY <NID>

This function enables the user to view details of patients currently in Hospital or discharged within the last 3 days. The system will search across all the hospitals in the local area, not just the hospital to which you are logged in.

NOTE: Remember that this function searches all the hospitals in the area, so you may need to go through several screens in order to find the patient you are looking for. This very much depends on the search that you performed.

1. Select the function <NID>.

2. NAME – Enter surname or part surname of patient.

A list of patients matching the criteria you have requested will be displayed, e.g.:

Status (Stat) of Stay: If blank, patient is still on ward.DSCI = Discharged, Coding IncompleteDSCC = Discharged, Coding CompleteSUSP = Suspended – Patient on Home LeaveDECD = Deceased (* in Dead Column)

3. If no patient matching the criteria is found or selected the screen will display:

Try again? Y / N. If Y (YES) entered will return to name prompt.

If N (NO) entered you can Search on Pre-admission? Y / N.Or, Search on Waiting List? Y / N.

This function can be used to find a patient and then recall them for any of the other functions available, e.g. transfer, discharge.

PMI Basic – v 4.5 17

1. Select appropriate patient from list using the selection number on the left hand side of the screen.

2. The screen will now return to the main menu, e.g. LIS, EPI.

Select appropriate function from menu.

Type in the letter L (for last patient selected) in any of the top 5 fields and <RETURN>.

The patient details will now appear on screen.

PMI Basic – v 4.5 18

13. INPATIENT NAME ENQUIRY < NI >

This function works in exactly the same way as function NID (as above). The difference is that in NI, the system will search only within the Hospital which you have logged in as, i.e. QAH / SMH.

NOTE: RHH displays under QAH (RHH wards are shown with the letter ‘Y’ at the beginning of the ward code).

PMI Basic – v 4.5 19

14. INPATIENT LOCATION LISTS <IPL>

This function enables you to print off various patient lists.

1. Select the function <IPL>.

2. At the List prompt use F9 to display the options:

3. Select the required list by moving the highlighted bar to the appropriate option, e.g.: WARD NAME*.

* The WARD NAME list is very useful to validate the names of those patients who should be inpatients on a ward. This will also show patients booked out on home leave (suspended admission) and their expected return date.

4. Enter the required details using F8 and F9 to help you.

5. If the report is to be printed type in the printer number at the Destination prompt. If the report is to be displayed on the screen type in TERM at the Destination prompt.

PMI Basic – v 4.5 20

15. PATIENT PATHWAY VIEWS <VPP> <VPA>

The functions VPP – Patient Pathway View and VPA – Patient Pathway View Archive all look and see access to patients’ 18 week pathways.

The functionality is the same in each function. A closed pathway will only show in VPP for up to 30 days from the date it was closed, there after it can be viewed in VPA

1. Log on in the usual manner.

2. Search for patient using LIS function. Select patient.

3. Select Function <VPP> or <VPA>. Type ‘L’ for last patient selected.

4. Screen displays two options:

a. Select an option or press the F1 key to return to the function set menu.

5. Both options will list the relevant pathways showing the Pathway Number and Condition, Start and End dates, Status code and Referral to Treatment (RTT) Waiting time:

a. Select a pathway or press the Enter key to return to the previous screen.

6. Selecting a pathway from option 1 – View a Pathway will display that pathway in more detail:

PMI Basic – v 4.5 21

a. Press the Enter key to return to the previous screen.

7. Selecting a pathway from option 2 – View Pathway Episodes will display all Episodes linked to that pathway:

a. Press the Enter key to return to the previous screen.

PMI Basic – v 4.5 22

16. GP AND DENTIST ADDRESS LABELS <GPL> AND <GDA>

This function enables the printing of labels for a specific GP/GDP.

1. Select function <GPL> or <GDA>, press <RETURN>.

2. GP/GDP Code - Enter if known, if not use F9 Superhelp, and search for Doctor’s/Dentist’s surname or partial surname - select from list.

3. Destination - Enter printer name or number.

4. Copies - Enter number of labels required (defaults to one).

Remember labels: 1 Copy = 12 labels.

5. Enter Y (YES). If you enter N (NO), it will take you back to GP/GDP Code.

6. F1 to exit.

PMI Basic – v 4.5 23

17. CASENOTE NUMBER LOCATION EXPLANATION LIST

All case note numbers start with one or more alphabetical characters. These can tell you about the origination of that case note number.

Prefix in Case Note No Column

Code in Current Location Column

Used by Comment

Q HRLM Acute Casenotes issued at QAH and at any other acute location (2010 onwards). Notes are filed at Health Records Mitchell Way.

S HRLM Acute Numbers were issued at St Mary’s Hospital, Royal Hospital Haslar, Emsworth Cottage Hospital, Gosport War Memorial Hospital, Havant War Memorial Hospital or Petersfield Community Hospital. The notes are now filed at Health Records Mitchell Way.

RH HRLM AcuteEQ HRLM AcuteG HRLM AcuteHW HRLM AcutePQ HRLM AcuteAny of the above

NCI Acute No Casenotes Issued. Some departments issue Casenote numbers but do not make up an actual Casenote folder as they have nothing to go in it. For subsequent activity when a folder is required - DO NOT ISSUE ANOTHER CASENOTE NUMBER. Request the folder from Health Records Library. Enter the PMI Add & Revise function and change Casenote Location as appropriate, e.g. QAH.

J LSJ Community Number created and notes filed at Medical Records St James’s Hospital. These notes are used to record mental health and community services activity.

J Various Community Number created at St James’s Hospital but notes filed at location where patient is a long term patient ie Mental Health Clinic.

* QE QER Eye Department

Eye Department Notes Only.

* R RTD Radiotherapy/ Oncology

Radiotherapy Notes Only.

* These are separate numbers from General Hospital Casenote Numbers which are used for recording some activity within these departments eg Outpatient Appointments. If the patient is on the PMI with only a QE number or R number number DO NOT register on PMI again, just add the required Casenote Number on to the existing registration.

Any IMG or MF Do not use Imaged/Microfilmed. Notes which are digitally imaged or Microfilmed. The status is withdrawn and date this took place (if known). NB: Imaging has now superseded microfilming notes.

Any MER Do not use Merged. If two sets of notes are merged together the number which is no longer used must be merged on PMI. Only specified people have access to merge notes. Change location to MER. Ensure status is withdrawn and date this took place.

H HREF Do not use Notes used at Haslar prior to amalgamation. Do not use to record information as they are for reference only.

B REG Do not use Birth registration only. Registered on the system when the baby is born. If the baby /child attends after this a Hospital Casenote Number must be made up and used. REG (baby number) status to be changed to withdrawn.

GPN GPN Do not use Casenote number originally issued by a GP when fast tracking a patient referral through GP links or Choose and Book. Episodes using this number should be revised to use the Acute casenote number.

IW IOW Do not use Isle of Wight Casenote Numbers - Not used for patient activity here. If required add Portsmouth Number to existing PMI Registration.

PMI Basic – v 4.5 24

Prefix in Case Note No Column

Code in Current Location Column

Used by Comment

CC COM Occupational Therapy

These numbers are used for Community Services only. They are in fact barcode records and not actual case note folders. They should NOT be used to record PHT or AMH activity.

CF COM Child & Family Therapy

CH COM PodiatryDE COM DentalLD COM Learning DisabilitiesDN COM District NursesEP COM Elderly Mental HealthFP COM Family PlanningPN COM Psychiatric NursesPT COM PhysiotherapySN COM School NursesST COM Speech TherapyVH COM Health Visitors

PMI Basic – v 4.5 25

18. EPISODE STATUS DESCRIPTION

IP ADM - Current InpatientIP SUSP - Patient out on home leave

DSCH INCPT - Inpatient Discharged - Coding IncompleteDSCH CMPLT - Inpatient Discharged - Coding CompleteDIED INCPT - Inpatient Died – Coding IncompleteDIED CMPLT - Inpatient Died – Coding Complete

A+E ATN - Accident & Emergency Attendance

WL ACTV - Patient on Inpatient Waiting ListWL DEFER - Patient on Deferred Inpatient Waiting ListWL SUSP - Patient on Suspended Inpatient Waiting ListWL CANC Patient Cancelled from Inpatient Waiting List

CEA - Cancel Treatment - Elective Add. CEA may appear under the status on some episodes, this is to indicate the patient was Admitted and Discharged without having had treatment and is placed back on the Waiting List.

PRE ADM TCI - Pre-Admission - To Come In - Date OfferedPRE ADM CANC

- Pre-Admission Cancelled

PRE *** - Pre-Admission Date Past - Patient Not Admitted

OP REG - Outpatient Appointment EpisodeOP DSCH - Discharged from Outpatients

WA ATT - Ward Attender – AttendedWA EXP - Ward Attender – ExpectedWA CNC - Ward Attender – CancelledWA DNA - Ward Attender - Did Not AttendWA WLK - Ward Attender - Walked InWA *** - Attendance Date Passed - Outcome not Recorded

SG REG - Service Group ReferralSG DSCH - Discharged from Service GroupSG - Indicates a Patient Contact attached to the Service Group

Referral

IP SUMM - Isle of Wight Use Only (Inpatient Summary)OP SUMM - Isle of Wight Use Only (Outpatient Summary)

PMI Basic – v 4.5 26

19. SPECIALITY CODE LIST100 General Surgery 401 Clinical Neuro-Physiology101 Urology 410 Rheumatology102 Transplant Surgery 418 Convalescent103 Breast Surgery 419 Pre-Convalescent104 Colorectal Surgery 420 Paediatrics105 Hepatobiliary & Pancreatic Surgery 421 Paediatric Neurology106 Upper Gastrointestinal Surgery 426 Special Care Baby Unit107 Vascular Surgery 427 Neonatal Intensive Care Unit109 Renal Surgery 430 Geriatric Medicine110 Trauma & Orthopaedic Surgery 450 Dental Medicine Specialties120 ENT 501 Maternity130 Ophthalmology 502 Gynaecology140 Oral Surgery 506 Infertility141 Restorative Dentistry 510 Maternity Ante Natal142 Paediatric Dentistry 520 Maternity Post Natal143 Orthodontics 528 Well Babies150 Neurosurgery 560 Midwife Maternity Event156 Spinal Injury 610 GP (Maternity Function)160 Plastic Surgery 620 GP (Other)166 Burns Unit 628 GP (Dental)170 Cardiothoracic Surgery 700 Mental Handicap171 Paediatric Surgery 710 Mental Illness176 Cardiac Surgery 711 Child & Adolescent Psychiatry177 Thoracic Surgery 712 Forensic Psychiatry180 Accident & Emergency 713 Psychotherapy190 Anaesthetics 715 Old Age Psychiatry199 Pain Relief 716 Adolescent Psychiatry300 General Medicine 717 Child Psychiatry301 Gastroenterology 719 Alcoholic Unit302 Endocrinology 728 Drug Dependency303 Haematology – Clinical 729 Elderly Mental Illness/Health304 Clinical Physiology 738 Child Assessment305 Clinical Pharmacology 758 Child Psychiatry Group Contact306 Haemophilia 800 Radiotherapy307 Diabetic Clinic 810 Radiology308 Bone & Marrow Transplantation 820 General Pathology309 Haemophilia 821 Blood Transfusion310 Audiological Medicine 822 Chemical Pathology311 Clinical Genetics 823 Haematology312 CL.Cytogenic / Molecular Genet 824 Histopathology312 Clinical Immunology & Allergy 830 Immunopathology314 Rehabilitation 831 Medical Microbiology315 Palliative Medicine 832 Neuropathology318 Unit For Younger Disabled 841 Metabolic Medicine320 Cardiology 900 Community Medicine326 Pacemaker 901 Occupational Medicine330 Dermatology 990 Joint Consultant Clinic340 Thoracic Medicine 4301 Elderly Acute350 Infectious Diseases 4302 Acute Stroke360 Genito-Urinary Medicine 4303 F/S Stroke Rehab361 Nephrology 4304 Slow Stream Stroke Rehab370 Medical Oncology 4305 General Rehab371 Nuclear Medicine 4306 Continuing Care376 Paediatric Oncology 4307 Shared Care377 Oncology Continuing Care 4308 Post Acute400 Neurology

PMI Basic – v 4.5 27

20. PATIENT ADMINISTRATION SYSTEM (PAS) DEFINITIONS

20.1. IntroductionThis paper is aimed at users of the PAS and intends to give the national definitions to some of the fields contained within the system. Also shown with some of the definitions are examples of the categories that should be collected. The categories will be the national written text, which may differ slightly to what is shown on PAS.

These definitions have been extracted from the NHS Data Dictionary which is used by all NHS Trusts in one form or another. This enables all Trusts to collect the same details, in the same manner. For example, when a patient is discharged from hospital after an Inpatient episode, one of the fields to be completed is the “Destination on Discharge”. This records where the patient is residing after care. The majority of times the response in this field would be “Usual Place of Residence” (ie Home). But other options can be selected here such as: Penal Establishment, Court, Hospice and Temporary place of Residence.

This list is not exhaustive, as there are many data items collected throughout the NHS. This list “touches” on some of the most common fields in PAS and hopes to give users the “true” definitions behind the information they are collecting. For those users, wishing to view the complete NHS Data Dictionary, this can be found on the Internet, using the following web address: http://www.nhsia.nhs.uk/datastandards/pages/ddm/index.htm

20.2.Description of episode types

Ward Attender

Ward attenders are patients who come into a ward to receive nursing care, but have not been admitted to hospital and do not stay in the ward. They may need care because of diseases or injuries or other factors such as pregnancy that can affect their health. You need to record details about these patients since they use ward resources, such as staff time and other facilities.

Day Case A patient admitted electively during the course of a day with the intention of receiving care who does not require the use of a hospital bed overnight and who returns home as scheduled. If this original intention is not fulfilled and the patient stays overnight, such a patient should be counted as an ordinary admission.

Ordinary Admission

A patient not admitted electively, and any patient admitted electively with the expectation that they will remain in hospital for at least one night, including a patient admitted with this intention who leaves hospital for any reason without staying overnight. A patient admitted electively with the intent of not staying overnight, but who does not return home as scheduled, should be counted as an ordinary admission.

Outpatient (Appointments)

A series of out-patient attendances consultant will form a consultant out-patient episode, generated from a single referral. Note that it is possible to have two consultant out-patient episodes with the same consultant for different clinical conditions, if two referrals are made.

Regular Day Admission

A patient admitted electively during the day, as part of a planned series of regular admissions for an on-going regime of broadly similar

PMI Basic – v 4.5 28

treatment and who is discharged the same day. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the patient no longer requires frequent admissions

Regular Night Admission

A patient admitted electively for the night, as part of a planned series of regular admissions for an on-going regime of broadly similar treatment and who is discharged in the morning. If the intention is not fulfilled and one of these admissions should involve a stay of at least 24 hours, such an admission should be classified as an ordinary admission. The series of regular admissions ends when the patient no longer requires frequent admissions.

20.3.List of definitions

Field Name on PAS(National Field Name)

Description (Example of options available)

Dest on Discharge (Discharge Destination)

The destination of a patient on completion of a Hospital Provider Spell, or a note that the patient died or was a still birth. (Usual Place of Residence, Hospice, Court)

Disch Date (Discharge Date)

Date of discharge from Hospital Provider Spell.Meth of Discharge(Discharge Method)

The method of discharge from a Hospital Provider Spell. (Died, On Medical Advice)

DT on List(Date of decision to Admit)

The date a decision to admit was made

Delivery Method The method by which a woman is delivered of a baby which is a registrable birth(Breech, Spontaneous vertex)

Did Not Attend Reason This records the reason why a patient did not attend an out-patient clinic when an appointment had been made. This is also used when a patient did not attend other types of healthcare (i.e. Waiting List Admission, Healthcare Contact)

Mode of Arrival(A&E Arrival Mode)

The means by which a patient arrived at an Accident and Emergency Department. (Brought in by Ambulance, Other)

New or Follow Up(A&E Attendance Category)

An indication of whether a patient is making first or follow-up attendance at a particular Accident and Emergency Department. (First Attendance, Follow Up Attendance Planned, follow Up Attendance unplanned)

Disposal(A&E Attendance Disposal)

A coding of the ways in which an accident and emergency attendance might end. (Admitted to hospital bed, discharged, Referred to Fracture Clinic)

Type of Incident(A&E Location Type)

The type of place where the incident occurred which led to an accident and emergency episode

Disposal DT(A&E Discharge Time)

The time recorded using a 24 hour clock that a patient leaves an Accident and Emergency Department after an accident and emergency attendance has concluded.

Tracking DT(A&E Initial Assessment Time)

The time a patient not needing immediate treatment, is assessed by medical or nursing staff in an Accident and

PMI Basic – v 4.5 29

Field Name on PAS(National Field Name)

Description (Example of options available)

Emergency Department to determine priority for treatment. The assessment should be conducted by medical or nursing staff who have received appropriate training in triage.

Category(A&E Initial Triage Assessment Category)

The category assigned to a patient as a result of an initial assessment by medical or nursing staff in an Accident and Emergency Department. The triage category is used to determine the PATIENT's priority for treatment.

Priority(A&E Patient Priority)

A priority communicated to the patient following assessment which determines the urgency with which the PATIENT will be treated. This is based on locally agreed triage categories

Seen D/T(A&E Time Seen for Treatment)

The time, recorded using the 24 hour clock, that the patient is seen by a health professional to diagnose the problem and arrange or start tests and start treatment as necessary.

Seen D/T(A&E Treatment)

A broad coding of types of treatment or guidance which may be provided to a patient as a result of accident and emergency attendances

Diagnosis(A&E Diagnosis)

A broad coding of types of diagnoses which may be made as a result of accident and emergency attendances

Meth of Adm(Admission Method)

The method of admission to a hospital provider spell. (Waiting list, Booked, Planned, Emergency – GP, Emergency – A&E)

Booking Type(Admission Booking Type)

A classification of the type of booking system used for the patient's admission. (Traditional Method, Partial, Full)

Booking Type(Appointment Booking Type)

An indication of the type of booking system used for allocating the out-patient appointment.

Attendance D/T(A&E Arrival Date)

The date of arrival of a patient in the Accident and Emergency Department.

Appt D/T(Attendance Date)

The date of an attendance, or appointment to attend, for example at a consultant clinic, nurse clinic, Accident and Emergency Department, or by a Ward Attender

Attend/DNA(Attend or Did Not Attend)

This indicates whether or not a person or patient attended for an appointment. If the patient did not attend it also indicates whether or not advanced warning was given. (Appointment Cancelled, Did not Attend, Patient Arrived Late and was not seen)

Birth Length The length of a baby at birth. This should be recorded in CMS and forms part of the neonatal clinical option.

Birth Order The sequence in which the baby was born, if part of a delivery having multiple births.

Birth Weight The weight of a baby at birth. This should be recorded in grams.

Clinic Code An identifier for a clinic. Normally related to a Condition, Consultant or Specialty

Clinic Description(Clinic Name)

The name of Out-Patient Clinic. The description for the Clinic code.

Date of Death(Death Date)

The date on which a person died, as recorded on the Death Certificate.

Last Reviewed(Elective Admission

The date on which an elective admission list entry was last reviewed.

PMI Basic – v 4.5 30

Field Name on PAS(National Field Name)

Description (Example of options available)

Review Date)Removal Reason(Elective Admission Removal Reason)

This records the reason why a patient was removed from the elective admission list

Reason Code(Elective Admission Suspension Indicator )

A reason for suspending an elective admission list entry.

Removal Date(Elective Admission List Removal Date)

Date removed from the elective admission list. Removal may be due to admission to a hospital provider spell, death or other reasons.

Appt Type(First Attendance)

This indicates whether a patient is making a first or follow-up attendance.

Appt Type(Initial Contact)

An indication of whether the face to face contact is the first occasion on which a patient is seen by the particular professional staff group service, or any staff group of the health care provider.

Intd Mgmt(Intended Management)

This is the intended pattern of bed use for a patient, decided when the decision is made to admit. This only applies to patients on the elective admission list.

Live or Still Birth Indicator

An indicator of whether the birth was a live or still birth. A still birth is a birth after a gestation of 24 weeks (168 days) where the baby shows no identifiable signs of life at delivery.

Exp Adm Date/Time(Date Offered for Admission Date)

Date offered for admission to hospital to start a hospital provider spell.

Disposal(Outcome of Attendance)

This records the outcome of an out-patient attendance consultant.(Discharged from Consultants Care, Another Appointment given, Appointment to be made at a later date)

Pat Class(Patient Classification)

A coded classification of patients who have been admitted to a hospital provider spell. (Ordinary Admission, Day Case, Ward Attender)

Decision to Refer(Referral Date)

The date on which the referral was made, as recorded on the referral request.

Referral Date(Referral Request Received Date)

This records the date the referral request was received

Disabled(Registered Disabled)

An indicator used to record whether or not an employee is registered as disabled.

Sex(Sex)

The sex of patients intended to use a ward or nursing home indicated in the operational plans (Male, Female, Either Sex)

Source of Adm(Source of Admission)

The coded source of admission to a hospital provider spell or a nursing episode when the patient is in a nursing home.

Initiator of Attendance(Source of Referral A&E)

A classification which identifies the source of referral of each accident and emergency episode. (GP, Self Referral, Work)

Ref By(Source of Referral Outpatients)

A classification which is used to identify the source of referral of each consultant out-patient episode.

Specialty(Specialty Code)

A unique code identifying each specialty designated by Royal Colleges. (General Surgery, Urology, Orthopaedics)

PMI Basic – v 4.5 31

Field Name on PAS(National Field Name)

Description (Example of options available)

Transport(Transport Arranged Indicator)

An indicator showing whether transport has been arranged for the patient.(Yes, No)

Produced by: ICT Information ManagerIssue Date: 03/02/03Revision Date: 14/07/11

PMI Basic – v 4.5 32

21. FAULT REPORTING

From time to time you may experience problems with faulty equipment, software problems or access to the Patient Administration System (PAS) ie password non acceptance problems. To resolve your problem a call with need to be logged with the ICT Service Desk.

21.1. ICT Service Desk

Email ict.servicedesk@iphis.nhs.uk

Phone 023 9268 2680 or SJH (7703) 2680.

You will need to give the Service Desk certain information, so always ensure you have the following information available. They may need to know:

Your Username.

The KB Number of the equipment. This is found on a small label (usually red or blue) stuck to the equipment.

The clinical system you were working on.

The patient’s details e.g. case note no.

Exactly what you were attempting to do, e.g. log on, view a patient’s results.

21.2.Out of office hoursContact the ICT Service Desk and leave a message on the answer machine. They will deal with the problem as soon as they can. Alternatively email them.

If you feel there is a major system problem contact the switchboard for them to contact the engineer on call.

PMI Basic – v 4.5 33

21.3. ICT TrainingIf you identify an error in this manual or think that it would be useful to include something that has not been covered, please contact ICT Training.

Email ict.training@iphis.nhs.uk

External Phone 023 9228 6000

Internal Phone QAH (7700) 586722. HELP WITH USING PAS

If you have only just attended the course and feel you may need additional support, help or advice, you can contact the ICT Training Office.

* If you have not used PAS for more than 12 months you will be required to re-attend your training.

Email ict.training@iphis.nhs.uk

External Phone 023 9228 6000

Internal Phone QAH (7700) 5867

PMI Basic – v 4.5 34

23. ICT TRAINING CANDIDATE APPEALS PROCEDURE..

Candidates who are unhappy with any aspect of the end of course/test assessment decision should first discuss the problem with the ICT Trainer at the time of receiving the result.

The reasons must be made clear by the candidate at this time.

If the candidate is still unhappy with the result further discussion should take place involving the ICT Training Team Leader within 3 days of the course/test date.

The ICT Training Department will keep a record of such discussion together with date and outcome.

Where necessary the 1st marker will be asked to re-mark and the marking checked by the ICT Training Team Leader.

It should be noted that if the candidate was borderline double marking should already have been undertaken.

If this does not provide satisfaction the candidate may raise a formal appeal.

Appeals will only be accepted if made in writing (not e-mail) to the ICT Training Manager within 10 days of the candidate receiving their result, outlining clearly the circumstance of the appeal.

The 1st & 2nd markers will meet with the Training Manager to consider if there are any aspects that should be taken into account in the candidate’s performance.

In some circumstances the candidate may be offered a re-test (e.g. hardware or software problems).

If this is not the case and the result remains unchanged then the candidate may write to the ICT Training Manager (within 5 days of receiving the 3rd result) who will consider all evidence and circumstances of the appeal also taking into consideration responsibilities to the Trust and Data Protection Act to make a final decision.

ICT Training, QAH, July 2011

PMI Basic – v 4.5 35

24. VERSION CONTROL/LOG

Manual Patient Master Index – BasicVersion 4.5Date July 2011Revisions PageNew NoneUpdated Added new header and footer to document and repaginated.

Updated Information Governance document. Updated candidates appeal procedure.

All5 & 638

Manual Patient Master Index – BasicVersion 4.4Date April 2010Revisions PageNew Section for VPP and VPA 21Updated Case note Location List – SMH, EMS, GWM, HWM, PCT, RHH now

at HRLM24

Manual Patient Master Index – BasicVersion 4.3Date September 2009Revisions PageNew Summary of search methods 8-2Updated Casenote Location List – PHT Health Records new location code.

Removed statement regarding the end of R and QE numbers.16-1

Manual Patient Master Index – BasicVersion V.N4.2Date January 2008Revisions PageDeleted Exercise 37

onwardUpdated Formatting and text refinements (unlisted as content and

meaning unchangedVarious

Manual Patient Master Index – BasicVersion V.N4.1Date November 2007Revisions PageDeleted 4/6 Exercise 1 35

onwardUpdated Exercise numbering 35

onward

PMI Basic – v 4.5 36

Manual Patient Master Index – BasicVersion V.N4Date May 2007Revisions PageUpdated Headers – to include IITT accreditation AllUpdated www.training.iphis.nhs.uk added to contact details 2Moved Confirmation of Details Procedure 7New Definitions of # * and & on Matching Patient Records screens 11Moved Sections on NI and NID have been swapped to accommodate new

teaching orderUpdated Revised format of the Case note Number Location Explanation List 21Updated Format and contact details re PAS applications/Helpdesk 29New Copies of classroom exercises , evaluation form and student

details appended to back of manualUpdated Text refinements (unlisted as content and meaning unchanged) Various

Manual Patient Master Index – BasicVersion V.N3Date February 2006Revisions PageDeleted CPE Patient Contact Enquiry - Moved into HC1 (Health Care Wide

Scheduling) function setNA

Updated Cross Site Access – Re-ordered information 10New Search Procedures – Added statement regarding search on

Preferred Name13

Updated Text refinements (unlisted as content and meaning unchanged) VariousManual Patient Master Index – BasicVersion V.N2Date 12 December 2005Revisions PageUpdated Information Governance

Replaces previous Data Protection and FOI information6

Manual Patient Master Index – BasicVersion V.N1Date December 2005Revisions PageUpdated Format update (front page, screen shots, font, layout, headings) AllNew Course Criteria sheet added 3Updated Keyboard layout (new pics) 4Updated Data Protection and FOI Act information 6Moved Document Print section moved to later in manual 17New New sections: CPE, IPL, NID 17, 19Updated GP and GDP labels sections merged 20Updated Speciality code list 24Updated Fault reporting (contact details) 29Moved Fault reporting section 29New Training Appeals Procedure 31

PMI Basic – v 4.5 37