Recording Demographic Details Back to Basics Kay Fairy & Pip Wardle ICT Services 22 nd January 2010
Introduction Every week NUH produce thousands of letters and reports which are destined for Patients and G. P’s. Hundreds of these letters and reports are never received, or are received late because we had out of date or incorrect demographic details on our Hospital Systems. This guide covers the basic principles of capturing and recording Patient Demographic Details on PAS.
Ask Patients the ‘Right’ Questions Use every opportunity - Check Patient Demographic Details (e. g. at Outpatient Reception, in the Emergency Department or on Admission) Always ask the Patient to confirm their; – Registered G. P & Practice – Home Address – Home & Mobile Telephone Number – Ethnic Group & Overseas Visitor Status (if not already recorded) DO - Ask ‘Open’ Questions “Could you confirm the name of your registered G. P and Practice Address” DON’T - Ask questions that require a Yes or No answer “Are you still with the same G. P” OR “Has anything changed since the last time you came”? If any details have changed… Ask for the date the change took place. Unsure of spellings? Ask the Patient to verbally spell or write the word for you.
Update Systems / Casenotes Update hospital systems immediately after a change has been identified. P Enter the date the change took place (don’t automatically enter ‘today’s date) P Take care when selecting the G. P from the pick list available Remember • Lots of G. P have the same name • The same G. P can work at different surgeries • Health Centres often house more than one surgery • The list of G. P’s is often displayed on more than one page P Use different search criteria to find the correct G. P • Search by name only or address only • Search by a combination of name and address • Use a ‘National’ search to find ‘out of area’ G. P’s Remove old front sheet and labels from casenotes, and replace with updated version.
Patients not registered with a G. P / G. P Unknown Where it is not possible to enter a valid G. P Name & Practice, either because the Patient is not registered with a G. P or does not know their G. P, enter the appropriate ‘dummy’ G. P code in the ‘National Code’ field. G 9999981 Patient not registered with a G. P G 9999998 G. P Unknown Use Right arrow key to display page 2, and select G. PUnknown from the list available
Know the G. P, but not available to select? On occasions where you have unsuccessfully tried to find the G. P Name and Practice using various search options, you may enter the G. P details using the ‘Free Text’ option. Enter the G. P’s Name and Practice Address in full Please Note; The Data Quality Team routinely follow-up on G. P’s that unknown to the system.
G. P Ceased Practicing Where a Patient is still showing as being registered with a G. P that has ceased practicing, the G. P Name and Practice must be updated with; An alternative G. P Name & Practice Address OR Where the Patient has not re-registered with a new G. P, G 9999981 ‘Not registered with a G. P’ should be entered.
Students Correspondence Address Students often prefer correspondence to be sent to an alternative address. Use the Mailing Address field, rather than the ‘Address’ field to record this address – don’t forget to add an ‘end date’ G. P Name & Address Students are often referred by a G. P Practice on a University Campus, but are still REGISTERED with a G. P from their home town. In this scenario, the G. P Name and Practice on the ‘G. P Details’ screen should show the registered G. P from their Home Town, however the referring G. P (a field found on Outpatient and Waiting List screens) should reflect the name of the G. P on the University Campus who referred the Patient.
Prisoners / Ministry of Defence Patients currently serving a Prison Sentence Address: Always enter the Prison Address. Never record the Prisoners Home Address G. P: Return past the G. P name and enter dummy code P 9999998 in the ‘National’ code field. Pick the relevant Prison from the list available. Patients serving in the Armed Forces Address: Enter the Patients preferred address G. P Return past the G. P name and enter dummy code A 9999998 in the ‘National’ code field. Pick the relevant MOD Barracks from the list available
Finally… Remember the 3 Golden Rules Don’t assume that the Demographic Details you see on the screen are correct, even if the Patient visit the hospital regularly – always check! Use every opportunity to check Demographic Details with a Patient (e. g. at the Point of Admission, attending an Outpatient Appointment, or presenting in the Emergency Department) Use OPEN Questions when asking a Patient to confirm their details. Don’t use questions that require a ‘Yes’ or ‘No’ answer!
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