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Patient Demographic Information Validation Policy

Documentation Control

Reference

Approving Body

Date Approved

Implementation Date September 2010

Version 1.0

Supersedes -

Consultation Information Governance Committee

Date of Completion of Equality Impact Assessment 10th August 2010

Target Audience All Trust staff who collect or process patient data

Supporting Documents and References

THI User Manual,Registrations, Merges & Demerges Policy, Recording Demographic Data – Back to Basics, NHS Data Dictionary, Data Quality Request form

Review Date September 2012

Lead Executive Director of Corporate Operations

Author/Lead Manager Steve Baxter

Nottingham University Hospitals NHS trust

Information ServicesPatient Demographic Information Validation Policy

Further Guidance/InformationHead of Information (policy issues) Ext 62009Deputy Director of Operations

Contents

Paragraph Title Page

1.0 Introduction 3

2.0 Scope of Policy 3

3.0 Policy Statement 5

4.0 Roles & Responsibilities 6

5.0 Equality and Diversity Statement 6

6.0 Equality Impact Assessment Statement 7

7.0 We Are Here For You 7

8.0 Validating & Amending Demographics at point of contact 7

9.0 Missing Demographic Data 8

10.0 Demographic Batch Tracing Service (DBS) 9

11.0 Duplicate Patient Records 9

12.0 PAS Systems and Interfaces 10

13.0 Reference Information 11

Appendix A Dummy Codes & Glossary 12

Nottingham University Hospitals NHS Trust


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Appendix B Equality Impact Assessment Report 13

Appendix C Employee Record of having Read the Policy 15

1.0 Introduction

1.1 Nottingham University Hospitals NHS Trust requires the collection, storage and management of patient data to be accurate, timely, relevant and secure in order to support the delivery of effective and efficient patient care and the achievement of the Trusts’ core business objectives and statutory obligations.

1.2 Good quality data is a fundamental requirement for the speedy and effective treatment of patients. Management information produced from patient data is essential for the efficient running of the organisation and to maximise utilisation of resources for the benefit of patients and staff.

1.3 All hospitals need to keep details about the patients who are seen there. These details include the Name, Address, Date of Birth, G.P Name and Address, Civil Status, Ethnic Group and the patients Religion. This is called demographic information

1.4 The purpose of this document is to ensure that the Patient Demographic Information MDS (Minimum Data Set) is complete. In order to achieve this, missing information should be identified and the appropriate action taken in a timely manner.

1.5 This document details the policies and procedure for identifying and implementing the processes needed, which will result in a complete and accurate Patient Demographic Information MDS.



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1.6 The following data items make up the Patient Demographic Information MDS. Many of these components are mandatory, however it is an essential requirement for all of these data items to be completed, either by entering the correct information, or by entering an appropriate dummy code.



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Surname Mandatory

Forename Mandatory

Date of Birth Mandatory

Age Mandatory

Sex Mandatory

Address Mandatory

Postcode

Civil Status Mandatory

Ethnic Group Mandatory

G.P Name

G.P Address

G.P Postcode

Religion Mandatory

2.0 Scope

2.1 This policy applies to the administrative and clinical patient related data contained within the Trusts’ electronic and paper based systems.

2.2 This policy compliments the following Trust policies:

Patient Data Quality Policy Health Records Management Policy Health Records Keeping Policy Information Security & Data Protection Policy Information Governance Policy

2.3 This policy is a statement of intent which members of staff are expected to follow and should be regarded as mandatory by all



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staff. Failure to follow a trust policy could result in disciplinary action being taken, up to and including dismissal.

3.0 Policy Statement

3.1 Patient data is collected and processed by many staff across the Trust. Data quality may be affected by a wide range of activities; the need for good quality data must therefore be embedded in the culture, values and actions of Trust staff.

3.2 The Trust will:

Ensure that operational and clinical staff are aware of the importance and value of good quality patient data

Provide accurate, complete and timely information to support commissioning, local information requirements and the information required for Commissioning Minimum Data Sets (CMDS)

Maintain the TotalCARE PAS/HISS Interface to ensure that demographic data is complete and that both indexes are synchronised

Ensure that the correct patient demographic information is available so that patients are easily identifiable and can be contacted without difficulty

Ensure that all data items are valid, and that any dummy codes are used appropriately, and adhere to data standards set out in the NHS Data Dictionary and will also ensure that locally developed standards are consistent with the NHS Data Dictionary

Ensure that all members of staff, who are responsible for the maintenance of missing demographic information, understand the policies and procedures outlined in this document



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4.0 Roles & Responsibilities

4.1 All staff are responsible for ensuring that they record patient data promptly and accurately with reference to the latest procedures and definitions.Departmental managers are responsible for monitoring patient data quality and for ensuring that their staff are aware of the importance of good quality patient demographic data.

5.0 Equality and Diversity Statement

5.1 All patients, employees and members of the public should be treated fairly and with respect, regardless of age, disability, gender, marital status, membership or non-membership of a trade union, race, religion, domestic circumstances, sexual orientation, ethnic or national origin, social & employment status, HIV status, or gender re-assignment.

5.2 All trust polices and trust wide procedures must comply with the relevant legislation (non exhaustive list) where applicable:

Equal Pay Act (1970 and amended 1983) Sex Discrimination Act (1975 amended 1986) Race Relations (Amendment) Act 2000 Disability Discrimination Act (1995) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act 1999 Code of Practice on Age Diversity in Employment (1999) Part Time Workers - Prevention of Less Favourable Treatment

Regulations (2000) Civil Partnership Act 2004



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Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001)

Employment Equality (Sexual Orientation) Regulations 2003 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Age) Regulations 2006

Equality Act (Sexual Orientation) Regulations 2007

6.0 Equality Impact Assessment Statement

6.1 NUH is committed to ensuring that none of its policies, procedures, services, projects or functions discriminate unlawfully. In order to ensure this commitment all policies, procedures, services, projects or functions will undergo an Equality Impact Assessment.

6.2 Reviews of Equality Impact Assessments will be conducted inline with the review of the policy, procedure, service, project or function

7.0 We Are Here For You

7.1 This Trust is committed to providing the highest quality of care to our patients, so we can pledge to them that ‘we are here for you’. This Trust supports a patient centred culture of continuous improvement delivered by our staff. The Trust established the Values and Behaviours programme to enable Nottingham University Hospitals to continue to improve patient safety, outcomes and experiences. The set of twelve agreed values and behaviours explicitly describe to employees the required way of working and behaving, both to patients and each other, which would enable patients to have clear expectations as to their experience of our services.

8.0 Procedures for Validating and Amending Patient Demographics at point of contact

8.1 An important part of the data capture process, is to obtain as much information as possible, directly from the patient themselves. When a patient is admitted, attends an outpatient appointment or



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presents in the emergency department every opportunity must be taken by staff to validate demographic details with the patient.

8.2 Every time a patient visits the hospital, staff should use the ‘Patient Demographic Information MDS’ (section 1.6) as a checklist to find out if any patient details have changed.

8.3 Staff should never assume that details displayed on screen are correct even if the patient is a regular attender at the hospital.

Always ask the patient to confirm their:

Name & Date of Birth

Home Address

Home & Mobile Telephone Number

Registered GP & Practice

Ethnic Group & Overseas Visitor Status (if not already recorded)

8.4 When asking a patient about demographic details it is important to always use ‘Open Questions’. Do Not use questions that require a simple ‘Yes’ or ‘No’ answer, i.e. Are you still with the same GP?

8.5 Always ask ‘Open’ questions. For example:“Could you confirm the name of your registered G.P. and Practice Address”

8.6 If any details have changed ask for the date that the change took place. Where staff are unsure of spellings, the patient should be asked to spell or write the word down.

Hospital Systems should be updated Immediately after any change is identified.



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Please refer to the ‘Recording Demographic Details – Back to Basics’ guide for further information.

9.0 Missing Demographic Data

9.1 Missing patient demographic information for Inpatients/Outpatients and Emergency Department is reported daily via missing data

reports, automatically generated by the PAS, HISS and EDIS systems and delivered to the Data Quality department.It is the responsibility of Data Quality staff to action the reports from the systems, and complete the missing information.

Searches for demographic data should use:

NHS Summary Care Record (SCR) systemhttps://portal.national.ncrs.nhs.uk/portal/dt

If the patient record is local to the Nottingham area and data cannot be traced using SCR, a search of the Open Exeter System should be used.

9.2 PAS/HISS/EDIS Missing Data Reports (Inpatient & Outpatient):

Missing GP’s Missing Postcodes Missing NHS Numbers Missing HAR’s Missing Practice Codes

10.0 Demographic Batch Tracing Service (DBS)

Batch tracing using DBS is carried out each week. The trace involves DBS NHS Number tracing. It is the responsibility of NUH ICT Services to complete the weekly batch tracing.



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https://portal.national.ncrs.nhs.uk/portal/dt

11.0 Duplicate Patient Records

Reports are sent to the Data Quality team on a weekly basis.Reports from the Patient Master Index (PMI) are received twice weekly from ICT Services in addition to a weekly report from Nations Treatment Centre. Members of the Admin/Clerical, Secretarial and Clinical staff often discover duplicate records. Data Quality should be informed of such instances either by email to DATA QUALITY (NUH) or logged via the data quality request form on the Information Services Intranet site:

http://nuhnet/operations/info_services/Pages/dataqualityrequests.aspx

Data Quality staff use the Summary Care Record (SCR), Open Exeter System, NotIS and EDIS systems to correct these errors.

Please refer to the Trusts Policy on Registrations, Merges and De-Merges for detailed procedure:

http://nuhnet/nuh_documents/Documents/Duplicate%20Registrations,%20Merge,%20Demerge%20Policy.doc

12.0 PAS Systems & Interfaces

The Nottingham University Hospitals (NUH) uses two different Patient Administration Systems to hold patient’s identifiers and demographic information, TotalCARE PAS (McKesson) and HISS (Hospital Information Support System).

The TotalCARE PAS to HISS Interface (THI), works as a link between TotalCARE PAS and HISS. Data entered into PAS is automatically copied by the THI into HISS, this means that no user duplicate entry is required. However, not all of the information is accepted by HISS, due to data discrepancies or miss-matches :

e.g. a registered G.P not on the HISS database.



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Therefore INBOUND transactions are generated by the system, which require user intervention before the information can be accepted.

The THI is not a 2 way interface, data that is entered into HISS is not automatically copied into TotalCARE PAS, instead the HISS system creates an OUTBOUND transaction, which includes details of any data entered so that the information can be manually copied into PAS.

It is the responsibility of the Data Quality team to take the necessary action, to clear both Inbound and Outbound transactions from the THI. These transactions are dealt with on a daily basis.

Please refer to the THI User Manual for details.

13.0 Reference InformationThe information needed to make up the Patient Demographic MDS can be obtained from many sources, although every opportunity should be taken to check a patients’ demographic details with the patient themselves.

Search Facilities within the PAS systemWithin PAS there are inbuilt search facilities, which help the user to search for a Post Code or a Registered G.P, please refer to training and user guides. If the relevant G.P cannot be found, use an appropriate dummy code (see appendix1)

Other useful sources of information

Patients Registered G.P G.P telephone number can be viewed on the patients’ record via PAS or HISS.

Open Exeter System Holds demographic information on Nottingham University Hospitals NHS Trust


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patients who live in the Nottingham area.NHS Summary Care Record (SCR)Demographic Batch Tracing Service (DBS)

Holds demographic information on patients for the whole country. This can be accessed via:https://portal.national.ncrs.nhs.uk/portal/dt

BT Post Code website National postcode search facility. This can be accessed via: www.royalmail.com/pat

Post Code Reference Books

Royal Mail Postcode reference books, located in Data Quality Offices.

Nursing Homes Directory A manually compiled directory of local Nursing homes, located in Data Quality.

Directory of family Doctorsand their services

Compiled by Nottingham Family Health Services Authority, located in Data Quality.



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https://portal.national.ncrs.nhs.uk/portal/dt

Appendix A

Dummy G.P CodesThe following codes should only be used when the patients registered G.P cannot be found. These codes should be added to the patients record on both the PAS and HISS Systems.

PAS Code HISS CodeUnknown G.P G9999998 UNKNOWN

Prison Doctors P9999981 MED

Armed Forces

(Services)

A9999998 MOD

No Registered G.P G9999981 REG

GlossaryCMDS Contract Minimum Data Set

MDS Minimum Data Set

NCH Nottingham City Hospital Campus

G.P General Practitioner

PAS Patient Administration System

HISS Hospital Information Support System

THI TotalCARE PAS, HISS Interface

References to other documents

(a)Recording Demographic Details – Back to BasicsNottingham University Hospitals NHS Trust


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(b)TotalCARE PAS Training & User Guides(c)THI User Manual

Appendix B

Equality Impact Assessment Report Outline

1. Name of Policy or Service

Patient Demographic Information Validation Policy v1.0

2. Responsible Manager

Steve Baxter – Head of Information

3. Name of Person Completing Assessment

S Baxter

4. Date EIA Completed

10 August 2010

5. Description and Aims of Policy/Service

Nottingham University Hospitals NHS Trust requires the collection, storage and management of patient data to be accurate, timely, relevant and secure in order to support the delivery of effective and efficient patient care and the achievement of the Trusts’ core business objectives and statutory obligations

This policy is a statement of intent which members of staff are expected to follow and should be regarded as mandatory by all staff and applies to the administrative and clinical patient related data contained within the Trusts’ electronic and paper based systems



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6. Brief Summary of Research and Relevant Data

7. Methods and Outcome of Consultation

8. Results of Initial Screening or Full Equality Impact Assessment:

Equality Group Assessment of Impact

Age No Impact Identified

Gender No Impact Identified

Race No Impact Identified

Sexual Orientation No Impact Identified

Religion or belief No Impact Identified

Disability No Impact Identified

Dignity and Human Rights No Impact Identified

Working Patterns No Impact Identified

Social Deprivation No Impact Identified

9. Decisions and/or Recommendations

Following the initial assessment, this policy does not have an impact either positively or negatively on any of the above strands of equality as the policy sets out the importance of the quality of data collection, for example the appropriateness on the electronic systems used to collect and record patient data not what data is actually being collected.

10. Equality Action Plan Nottingham University Hospitals NHS Trust


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N/A

11. Monitoring and Review Arrangements

This policy and associated documents should follow the NUH guidelines for monitoring and review once implemented.

Appendix C

EMPLOYEE RECORD OF HAVING READ THE POLICY

Title of Policy/Procedure: Patient Demographic Information Validation Policy

I have read and understand the principles contained in the named policy.

PRINT FULL NAME SIGNATURE DATE



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