patient master index · 5. add new patient details the following procedure should only be used if...

PMI Add and Revise – VN4.4 www.porthosp.nhs.uk/it-training

Patient Master Index (PMI)

PMI Add and Revise Version 4.3

Reviewed: April 2014

Next review date: April 2015

ICT Training First Floor, Victoria House Queen Alexandra Hospital

Cosham PO6 3LY Tel: 023 92 432333(Option 3)

Email: [email protected] Website: www.porthosp.nhs.uk/it-training

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.

http://www.porthosp.nhs.uk/

http://www.porthosp.nhs.uk/it-training

PMI Add and Revise – VN4.4 www.porthosp.nhs.uk/it-training 1

CONTENTS

1. GENERAL COURSE INFORMATION ................................................................... 2

2. INFORMATION GOVERNANCE ......................................................................... 3

2.1. What can you do to make Information Governance a success? ................... 3

3. CONFIRMATION OF DETAILS PROCEDURES ...................................................... 5

4. INTRODUCTION ............................................................................................ 6

5. ADD NEW PATIENT DETAILS <PMI> ................................................................ 7

5.1. Patient Basic Details Screen ................................................................... 7

5.2. Record Other Details ............................................................................ 10

5.3. Registration Details (Screen 2) .............................................................. 10

5.4. Casenotes (Screen 3) ........................................................................... 12

6. REVISE DETAILS OF AN EXISTING PATIENT <PMI> .......................................... 14

6.1. No. 1 – Revise Basic Details .................................................................. 14

6.2. No. 2 – Registration Details................................................................... 15

6.3. No. 3 – Casenotes ............................................................................... 15

6.4. No. 4 – Episodes .................................................................................. 16

7. MAINTAIN FUNCTIONS ................................................................................. 17

7.1. Maintain Address History <MAH> .......................................................... 17

7.2. Maintain GP History <MGH> ................................................................. 17

7.3. Maintain Surname History <MSH> ......................................................... 17

8. CASENOTE NUMBER LOCATION EXPLANATION LIST ......................................... 18

9. EPISODE STATUS DESCRIPTION .................................................................... 20

10. SPECIALITY CODE LIST ................................................................................. 21

11. PAS MASTERFILES – REQUEST FOR POSTCODE ............................................... 22

12. PAS MASTERFILES - REQUEST FOR GENERAL PRACTITIONER (GP)/ SURGERY ..... 23

13. PAS MASTERFILES – REQUEST FOR DENTIST .................................................. 24

14. AUTO POSTCODING HELP SHEETS ................................................................. 25

14.1. Ways of Searching ............................................................................... 25

14.2. Other Tips........................................................................................... 27

15. FAULT REPORTING ....................................................................................... 28

15.1. ICT Service Desk ................................................................................. 28

15.2. Out of office hours ............................................................................... 28

15.3. ICT Training ........................................................................................ 28

16. HELP WITH USING PAS ................................................................................. 28

17. ICT TRAINING CANDIDATE APPEALS PROCEDURE ............................................ 29

18. VERSION CONTROL/LOG ............................................................................... 30



Patient Administration System (P.A.S) Course

1. GENERAL COURSE INFORMATION

_______________________________________________________________________

COURSE TITLE PMI – ADD & REVISE

METHOD OF TRAINING Workshop (Classroom Delivery available by special request)

DURATION Recommended 2 Hours

PRE-REQUISITES PMI Basic – Level 0

_______________________________________________________________________

ABOUT THE COURSE

This course will show students how to enter a new patient onto the PAS system with full and

accurate details, and how to update records for existing patients with new information. Students

will also be shown how to view historical demographic information for a patient.

_______________________________________________________________________

SUITABLE FOR

All staff – Clerical and Clinical

_______________________________________________________________________

OBJECTIVES

This course will enable the student to:

1. Identify when a patient is NOT on PAS and needs to be added.

2. Add a new patient to the PAS system with all the patients’ demographic details and casenote

number.

3. Revise existing patient’s details.

4. Follow the correct rules and guidelines whenever adding or editing any patient information.

5. View address, GP and GDP history for a patient.

6. Identify specific information, e.g. GP, casenote number, etc.

7. Use the Auto-Postcoding system to find addresses using several different methods.

8. Deal with special case scenarios, e.g. No Fixed Abode and Military patients.



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, particularly about patients/clients and employees, and which is likely to be

personal, sensitive and confidential in nature. Information Governance 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 Confidentiality

o Records Management

o 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 secure

Ensure 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 confidential

Only 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 fairly

Inform 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 accurate

Check 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.

2.1.5. Only use information for the purpose for which it was given

Use 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.

Further information can be accessed through the Trust Intranet: Information Governance (Departments sections), and Management Policies (Policies section)



2.1.6. Share personal information appropriately and lawfully

Obtain patient consent before sharing their information with others e.g. referral to another agency

such as, social services.

2.1.7. Comply with the law

The 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.

All staff members should ensure that they only access confidential personal information on a strict

‘need to know’ basis. The Trust will actively monitor and audit access to confidential information, to

ensure that access is legitimate and that confidentiality and security policies are being followed.

There may be disciplinary proceedings as a result of inappropriate access which, for example, could

include staff members looking at their own records or the records of their family members (even if

they believe they would have consent). Staff members’ access to confidential patient information

must be clinically justified.

For further Information Governance training refer to:

ESR e-learning modules The Information Governance Training and Awareness Plan Revised by PHT Information Governance Manager, February 2013 Written by PHT Information Governance Manager, Sept 2010


http://www.igte-learning.connectingforhealth.nhs.uk/igte/index.cfm

http://pht/Departments/InformationGovernance/Information%20Governance%20Training/Forms/AllItems.aspx


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 (e.g. 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 2003

Reviewed: July 2011

Version 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



4. INTRODUCTION

The functions of PMI access level 1 enables you to ADD a patient to the Patient Master Index or

REVISE details of an existing patient. This process should be undertaken after searching for the

patient using the LIS function.

NOTE: ALWAYS SEARCH IN <LIS> AS IT IS THE ONLY FUNCTION WHICH GIVES A FULL SEARCH

OF THE PMI.

THOROUGH AND ACCURATE SEARCHES MUST BE MADE, FOLLOWING PMI LIS PROCEDURES.

The results of these searches will be:

No matching details found, in which case see ADD instructions (page 6).

Matching patient found. If some amendments needed – see REVISE instructions (page 13).

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



5. ADD NEW PATIENT DETAILS <PMI>

The following procedure should only be used if you have tried all of the different searching

techniques to ensure the patient does not already exist on the PMI.

5.1. Patient Basic Details Screen

Select the function PMI (Add/Revise) and enter patient details again using Surname, Forename,

Date of Birth and Sex. At try again prompt, enter NO, press <Enter>. By entering NO you are

indicating to the system that you don't want to search again, but wish to enter new information.

PAS NUMBER

Enter patient’s date of birth into PAS Number box without any formatting (i.e.: no dashes, commas

etc), and enter 6 digits only. E.g.: A date of birth of 23/05/1956 should be entered as 230556. The

system will allocate the last 2 digits automatically, it is important you allow the system to do this,

DO NOT enter 8 digits in the first place.

NOTE: If Date of Birth is unobtainable, e.g. Patient unconscious, Enter Z and press <Enter>. The

System will allocate a 'dummy' number.

NHS NUMBER (if known)

This is an important field so every effort must be undertaken to obtain the patient’s NHS number.

This and the patient’s demographic details can be found using the Summary Care Record system

(SCR).

MILITARY NUMBER (if applicable)

If applicable enter the military number for the patient.

SURNAME

Patient’s surname only.

FORENAMES

Patient’s fore name.

DOB

Patient’s Date of Birth. You will notice that the computer will calculate the patient’s age

automatically once you press <Enter>.

AGE

Only enter something in this box if you do not have a Date of Birth for the patient.

SEX

Choose from the 4 available options:

Female

Indeterminate (Sex of patient cannot be determined, i.e.: Premature baby)

Male

Not Known (Sex of patient Unknown)



PREFERRED NAME

Enter the name the patient prefers to be known by if different to the forename.

TITLE

E.g. Mr, Mrs, Miss, Ms.

Press Super-Help for a complete list of all available options. The list includes Military titles.

WORK PHONE

The patient’s main contact number should be recorded in the phone field, any other numbers, up to

two, can be recorded here.

PHONE

This field should be used to record the main contact number for the patient. Where possible the

Trust aims to record the mobile number to enable text message appointment reminders to be sent

to the patient, however this could be the patient’s home land-line if that is their preference. Only

one number must be recorded here in order to allow the Text Messaging to work.

ADDRESS (POP-UP WINDOW)

The screen will display boxes for Extended Address and PMI Address. This now allows you to access

the auto postcode search. The reasons for the 2 address boxes are:

The Extended Address (top box) will be used

to appear on patient letters. You will be able

to view this full address in Add & Revise.

The PMI Address (bottom box) will appear on

the basic details screen as normal. This

address will print on labels.

1. On the Extended line press F9 (Super-

Help). This will now enable you to perform

various search techniques to find the

address you need, some of your search

options are using:

HOUSE NUMBER, POSTCODE: Will return

one house only if found.

POSTCODE ONLY: Will return a list of all buildings covered by that postcode, select the building

required from the list, and press <Enter>.

STREET NAME, TOWN: Will return a list of all buildings down the specified street in that town.

Select building from list and press <Enter>.

HOUSE NAME, TOWN: Will return all buildings with the specified name within the town

specified. Select building from list and press <Enter>.

HOUSE NUMBER, STREET NAME: Will return a list of ‘locations’ anywhere in the country where

the system has found a matching house number and street name. Select a location and you will

then be presented with the available matches within that location.

WHOLE ADDRESS WITHOUT POSTCODE: If you enter a valid address in the correct format,

the system will return the postcode for that address, if it is correct, just press <Enter>.

At any point when searching for addresses, when you have a list on the screen, 2 options will always

be available at the bottom of the list:

Previous Level of Address: Will take you back one screen.

Change Selection Criteria: Will allow you to change your original address search.



2. When the correct address is displayed select it with the highlight bar and <Enter>. This will add

it to the Extended Address box.

3. <Enter> through the address boxes until the Basic Details screen is displayed. As you do so the

new address and postcode will update in the PMI Address box.

4. If the required address cannot be found, having tried several different search combinations,

delete all address details in the Extended Address box by pressing the F2 key. <Enter> to the

PMI Address Box and type in the address (including the postcode).

If the system accepts the address but not the postcode, leave the postcode field blank, and

complete a 'Missing Postcode Form' (sample on page 21).

NOTE: The address will not automatically appear until you have completed the ‘Enter?' <Y> yes

prompt on the PMI Basic Screen. You can use the F7 key to refresh the screen to display the new

address.

NOTE: Military Patient addresses on the front screen must always be their base address for

security reasons.

For more information about auto-postcoding, including how to deal with foreign addresses and no

fixed abode, please see page 24 of this manual.

MAINTAIN POSTAL ADDRESS

This box is used to provide a postal address for the patient’s correspondence that is an alternative to

their permanent place of residence. It is NOT used for entering in a previous address for the patient.

The default answer for this box is set to ‘NO’. Please leave this at NO unless you have been given

instructions on the use, rules and authorisation for this field.

In the case of Military Personnel you must enter the following address without stating an end date:

MDHU Portsmouth

Albert House

Queen Alexandra Hospital

Cosham

PO6 3LY

All letters for Military patients will go direct to MDHU (MPAC) and it will be their responsibility to

ensure the patient is informed and attends the planned appointment/admission.

COMMENTS

The purpose of this field is for use for the following information only:

Box No for deceased patient notes

Box No for moulds for MFU patients

Twins

. . . and in some cases doubles

Under certain circumstances other comments are entered into this field, but they are to be agreed

by the ECR Development Service Manager.

ENTER

To save the patient’s record on the system enter a ‘Y’ in this box and press <Enter>. If you do not

wish to save the record enter ‘N’



This is the front BASIC SCREEN of the patients’ registration. You must continue on to record other

details.

5.2. Record Other Details

You will automatically be taken into the Registration Details: Enter GDP (Dentist), GP (Doctor),

NOK (Next of Kin), Religion, Marital Status, Occupation, etc.

The word *Full*, now appears on the left hand side of the address, indicating that the extended

address box is complete.

Select appropriate number from the taskbar at the bottom of the PMI Basic Details screen to register

other details.

No 1 Revise Basic Details: Allows you to revise information in the Basic Details screen.

No 2 Reg Details: Enter GDP (Dentist), GP (Doctor), NOK (Next of Kin), Religion, Marital Status,

Occupation, etc.

No 3 Casenotes: Enter Casenote Number(s), etc.

No 4 Episodes: Display any episodic details.

5.3. Registration Details (Screen 2)

The questions on this screen ask ‘Do you wish to view?’ Answer YES or NO as required.

GDP and GP

Having selected <Yes> use F9 (Superhelp) at the ‘code’ prompt to locate the patient’s registered GP

or surgery and Dentist codes.

SEARCH ON – Enter Surname or part Surname to search, or in the case where a patient is

registered to a Surgery enter surgery name or part name. Screen will show selection list, select by

using Arrow Key until correct GDP/GP/Surgery is highlighted, press <Enter>.

Code prompt

Search on

Check this is the correct GDP/GP/Surgery required, press <Enter>.



NOTES:

Entry of the registered GP details is mandatory.

Remember to try different searches – try just the first letter(s) of GP’s surname, the full

spelling could be different, e.g. Taylor and Tailor.

Increasingly patients will be registered with a Surgery rather than an individual GP. Be

aware that you can search for surgery name in the Search On field.

For a MEDICAL OFFICER for SERVICE PERSONNEL search using the ‘military base’ name

e.g.: HMS NELSON search using NELSON.

GP NOT KNOWN/NOT REGISTERED

Recording the patient’s registered GP/Surgery is mandatory. However, there may be times when

you are unable to add a GP’s name or the Surgery to a patient’s details, for example:

1. If the Patient GP/Surgery is not known to the System or the Patient.

2. If the patient chooses not to give you their GP’s name.

3. If the patient is not registered with a GP/Surgery.

If this happens either search on NOT and the first letter of the second word or enter one of the

following codes:

000000 NOT KNOWN GP/SURGERY

000019 NOT GIVEN

000116 NOT REGISTERED GP/SURGERY

Remember to also complete a ‘Missing GP’ form and send to the relevant department (see sample

copy page 25).



NOK (NEXT OF KIN)

Enter Y (Yes) to view NOK.

Type in full name (free text) and relationship or press F9 (Superhelp) to select correct relationship.

If relationship is husband/wife, Partner, Civil Partner, or mother/child (16 or under), the address is

automatically entered although the cursor stays on the first line to allow for changes if required.

COMMENTS

Enter information as required, e.g. Ring after 6.00pm, etc.

NOTE: This information may only be viewed on this screen.

OTHER DETAILS

Religion } F9 (Superhelp) (Mandatory)

Marital Status } F9 (Superhelp) (Mandatory)

Place of Birth } Free Text

Ethnic Group } F9 (Superhelp) (Mandatory)

Occupation } Free Text

Occupation (Spouse) } Free Text

School (Child) } Free Text

It is essential that as much information as possible is entered.

5.4. Casenotes (Screen 3)

Select screen 3 <Enter>.

Casenote Enter NEW Casenote number – MUST include prefix letter(s).

Command Defaults to ADD <Enter>to accept.

Allocated Enter date Casenote number issued, <Enter> (Default today’s date).



Location Usual ‘home’ of Casenotes e.g. HRLM = Health Records Library at Mitchell Way, (F9

(Superhelp) will display possible choices). Also see Casenote Number Location

Explanation List (page 17).

Placed On Date notes made up – usually same as ‘allocated’ but could be a later date, <Enter>

(Default today’s date).

Comments Free text.

Status Defaults to ‘Current’ <Enter>to accept, screen asks if you wish to enter any more

numbers, e.g. microfilm numbers, etc., Y (Yes) or N (No) as appropriate.

CHECK CAREFULLY THAT YOU HAVE ENTERED THE CORRECT CASENOTE NUMBER. THIS CAN HAVE

SERIOUS IMPLICATIONS ON PATIENT CARE, E.G. UNABLE TO TRACE CASENOTES IF THE NUMBER

IS NOT ENTERED CORRECTLY



6. REVISE DETAILS OF AN EXISTING PATIENT <PMI>

1. Find the patient in LIS.

2. Recall the patient in PMI Add/Revise.

REMEMBER: Type ‘L’ to quickly recall the last patient displayed.

3. Select appropriate number from the taskbar at bottom of screen to enter the section

requiring amendments or additions.

6.1. No. 1 – Revise Basic Details

6.1.1. Change an Existing Address

Ensure that you have CAPS LOCK switched on.

1. <Enter> through the Basic Details screen until the Extended Address and PMI Address boxes

appear.

2. If the cursor is not in the first line of the Extended Address Box “up arrow”.

3. Press the F9 (Superhelp) key.

Search for the new address using a method described on page 7 or page 24.

4. When the correct address is displayed select it with the highlight bar and <Enter>. This will

add it to the Extended Address box.

5. <Enter> though the address boxes until the Basic Details screen is displayed. As you do so

the new address and postcode will update in the PMI Address box.

6. If the required address cannot be found, having tried several different search combinations,

delete all address details in the top (extended) address box by pressing the F2 key on each

line. <Enter> to the lower address box and type in the address (including the postcode).

If the system accepts the address but not the postcode, leave the postcode field blank, and

complete a 'Missing Postcode Form' (sample on page 22).

7. At “Address Move or Correction” type C for correction, or M for move.

CORRECTION is putting right errors (C).

MOVE is recording a new Patient Address (M).

8. For an address MOVE you must insert the date of move. If the correct date is not known you

must put in a date of at least 3 days before you are entering this change on the system (e.g.

T-3). This ensures ‘day end’ records information in the correct order.



REMEMBER: The address does not automatically change on the Basic Details Screen until you have

entered <Yes> at the Enter prompt. You may refresh the screen prior to this by pressing F7.

REMEMBER: ‘Maintain Postal Address’ does not relate to the address you have just entered. The

Default is NO please ensure it stays at NO unless you have had further instructions.

REMEMBER: It is essential we have a full address including postcode.

NOTE: If you are correcting/changing an address you are prompted to update the Next of Kin

address if required. This can still be updated in the registration screen if you prefer to do changes

there.

6.1.2. Change of Surname

1. Overtype the existing surname.

2. <Enter> through the remainder of the screen (including the address boxes).

3. Type <Yes> at the Enter prompt.

4. Answer <Yes> to retain the original surname with the patient’s record.

NOTE: Previous surnames must be retained, unless amending a spelling error. PAS will retain the

three most recent previous surnames.

6.2. No. 2 – Registration Details

This can be used to revise any GP/GDP/NOK and demographic details etc.

As with changing an address when recording GP or GDP changes select either Correction or Transfer.

For a transfer the date rule applies. If the correct date is not known you must put in a date of at

least 3 days before you are entering this change on the system (e.g. T-3). This ensures ‘day end’

records information in the correct order.

CORRECTING is putting right errors (C).

TRANSFER is recording a new GP or GDP (T).

REMEMBER - if the GP or GDP is not on the System follow instructions on page.

6.3. No. 3 – Casenotes

The casenote screen allows additional casenote numbers to be added or revision to the details of an

existing casenote number.

The screen will display the existing casenote number (if only one number allocated).

If nothing is displayed in the casenote number field use F9 (Superhelp) to list all casenote numbers.

To ADD another number - overtype the casenote number if displayed or enter new number in field

then complete details as required.

To REVISE details only of an existing casenote number – F9 (Superhelp) and select the casenote

number and amend details as necessary, e.g.



1. Withdrawing Baby Number (B) - amend Location and Status. Continue to add new casenote

number.

2. Updating A+E number only and NCI (no Casenotes issued) - amend Placed On date to reflect

date folder made up and Location.

See also casenote number location explanation list on page 17.

If you are unsure on casenote numbering, etc. please contact Registration in Health Records Library.

6.4. No. 4 – Episodes

This is used as a display function only. It shows episodic details. Displays from most recent record

at top of list.

(See Episode Enquiry – Episode Status Description list on page 19).



7. MAINTAIN FUNCTIONS

7.1. Maintain Address History <MAH>

This function is used to list previous addresses and to revise or delete an incorrect entry if

necessary.

NOTE: Be aware, if you amend a record in MAH there could be implications on the contract. If in

doubt check it out.

7.2. Maintain GP History <MGH>

This function is used to list previous GPs and to revise or delete an incorrect entry if necessary.

NOTE: The current GP is not displayed here.

NOTE: Be aware, if you amend a record in MGH there could be implications on the contract. If in

doubt check it out.

7.3. Maintain Surname History <MSH>

This function is used to view up to the THREE most recent surnames including the date that changes

have been recorded. It is also possible to revise or delete incorrect entries.



8. CASENOTE NUMBER LOCATION EXPLANATION LIST

All Casenote numbers start with one or more alphabetical characters. These can tell you about the

origination of that Casenote 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 Acute

EQ HRLM Acute

G HRLM Acute

HW HRLM Acute

PQ HRLM Acute

Any 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 i.e. 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 e.g. Outpatient Appointments. If the patient is on the PMI with only a QE number or R 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.

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 CF COM Child & Family Therapy

CH COM Podiatry



Prefix in Case Note No Column

Code in Current Location Column

Used by Comment

DE COM Dental used to record PHT or AMH activity. LD COM Learning Disabilities

DN COM District Nurses

EP COM Elderly Mental Health

FP COM Family Planning

PN COM Psychiatric Nurses

PT COM Physiotherapy

SN COM School Nurses

ST COM Speech Therapy

VH COM Health Visitors



9. EPISODE STATUS DESCRIPTION

IP ADM - Current Inpatient

IP SUSP - Patient out on home leave

DSCH INCPT - Inpatient Discharged - Coding Incomplete

DSCH CMPLT - Inpatient Discharged - Coding Complete

DIED INCPT - Inpatient Died – Coding Incomplete

DIED CMPLT - Inpatient Died – Coding Complete

A+E ATN - Accident & Emergency Attendance

WL ACTV - Patient on Inpatient Waiting List

WL DEFER - Patient on Deferred Inpatient Waiting List

WL SUSP - Patient on Suspended Inpatient Waiting List

WL 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 Offered

PRE ADM

CANC

- Pre-Admission Cancelled

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

OP REG - Outpatient Appointment Episode

OP DSCH - Discharged from Outpatients

WA ATT - Ward Attender – Attended

WA EXP - Ward Attender – Expected

WA CNC - Ward Attender – Cancelled

WA DNA - Ward Attender - Did Not Attend

WA WLK - Ward Attender - Walked In

WA *** - Attendance Date Passed - Outcome not Recorded

SG REG - Service Group Referral

SG DSCH - Discharged from Service Group

SG - 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)



10. SPECIALITY CODE LIST

100 General Surgery 401 Clinical Neuro-Physiology

101 Urology 410 Rheumatology

102 Transplant Surgery 418 Convalescent

103 Breast Surgery 419 Pre-Convalescent

104 Colorectal Surgery 420 Paediatrics

105 Hepatobiliary & Pancreatic Surgery 421 Paediatric Neurology

106 Upper Gastrointestinal Surgery 426 Special Care Baby Unit

107 Vascular Surgery 427 Neonatal Intensive Care Unit

109 Renal Surgery 430 Geriatric Medicine

110 Trauma & Orthopaedic Surgery 450 Dental Medicine Specialties

120 ENT 501 Maternity

130 Ophthalmology 502 Gynaecology

140 Oral Surgery 506 Infertility

141 Restorative Dentistry 510 Maternity Ante Natal

142 Paediatric Dentistry 520 Maternity Post Natal

143 Orthodontics 528 Well Babies

150 Neurosurgery 560 Midwife Maternity Event

156 Spinal Injury 610 GP (Maternity Function)

160 Plastic Surgery 620 GP (Other)

166 Burns Unit 628 GP (Dental)

170 Cardiothoracic Surgery 700 Mental Handicap

171 Paediatric Surgery 710 Mental Illness

176 Cardiac Surgery 711 Child & Adolescent Psychiatry

177 Thoracic Surgery 712 Forensic Psychiatry

180 Accident & Emergency 713 Psychotherapy

190 Anaesthetics 715 Old Age Psychiatry

199 Pain Relief 716 Adolescent Psychiatry

300 General Medicine 717 Child Psychiatry

301 Gastroenterology 719 Alcoholic Unit

302 Endocrinology 728 Drug Dependency

303 Haematology – Clinical 729 Elderly Mental Illness/Health

304 Clinical Physiology 738 Child Assessment

305 Clinical Pharmacology 758 Child Psychiatry Group Contact

306 Haemophilia 800 Radiotherapy

307 Diabetic Clinic 810 Radiology

308 Bone & Marrow Transplantation 820 General Pathology

309 Haemophilia 821 Blood Transfusion

310 Audiological Medicine 822 Chemical Pathology

311 Clinical Genetics 823 Haematology

312 CL.Cytogenic / Molecular Genet 824 Histopathology

312 Clinical Immunology & Allergy 830 Immunopathology

314 Rehabilitation 831 Medical Microbiology

315 Palliative Medicine 832 Neuropathology

318 Unit For Younger Disabled 841 Metabolic Medicine

320 Cardiology 900 Community Medicine

326 Pacemaker 901 Occupational Medicine

330 Dermatology 990 Joint Consultant Clinic

340 Thoracic Medicine 4301 Elderly Acute

350 Infectious Diseases 4302 Acute Stroke

360 Genito-Urinary Medicine 4303 F/S Stroke Rehab

361 Nephrology 4304 Slow Stream Stroke Rehab

370 Medical Oncology 4305 General Rehab

371 Nuclear Medicine 4306 Continuing Care

376 Paediatric Oncology 4307 Shared Care

377 Oncology Continuing Care 4308 Post Acute

400 Neurology



Portsmouth Hospitals NHS Trust, Primary Care Trusts, Portsmouth City, East Hants, Fareham & Gosport

11. PAS MASTERFILES – REQUEST FOR POSTCODE

Please print all information as writing cannot always be deciphered

Postcode

(max 10 char)

Health Authority Code

(max 4 char)

Patient Details

Casenote Number

Patient Name

Patient House No & Road

District

Town

County

Requester’s Full Name

Asset No (KB No)

Department

Full Address

Telephone Ext

Please send/email completed form to: [email protected] For Office Use Only:

Fax: 023 9268 3413 Date Receive


mailto:[email protected]



12. PAS MASTERFILES - REQUEST FOR GENERAL PRACTITIONER (GP)/

SURGERY


GP Full Name (including any middle names)

Surgery Address

Postcode

Telephone Number

GP Code

Practice Code

Organisation Code

PATIENT NAME AND CASENOTE NO (Must be entered)

Name

Casenote Number

D.O.B


Asset No (KB No)

Department

Full Address

Telephone Ext

Please send/email completed form to: [email protected] For Office Use Only: Fax: 023 9268 3413 Date Received:





13. PAS MASTERFILES – REQUEST FOR DENTIST


Full Name (including any

middle names)

Surgery Address

Postcode

Telephone Number

GDP Code

PATIENT NAME AND CASENOTE NO (Must be entered)

Name

Casenote Number

D.O.B


Asset No (KB No)

Department

Full Address

Telephone Ext

Please send/email completed form to: [email protected] For Office Use Only: Fax: 023 9268 3413 Date Received:




14. AUTO POSTCODING HELP SHEETS

14.1. Ways of Searching

14.1.1. Searching using F9 (Superhelp) Key

On the line labelled “Extended” press the Key F9 (Superhelp) and enter the chosen address details

on the search line.

Option 1 – Search using house number & Postcode

1. Enter the house number followed by a comma and then the postcode,

e.g. 53,GU16 6BJ then press <Enter> past postcode

2. The complete address will be entered for you – check that this is correct.

3. Press <Enter> until you return to the Basic Details Screen.

4. At the Enter prompt type: Y (Yes) to record patient’s address.

Option 2 – Searching using Postcode only

1. Enter the postcode you wish to search on then press <Enter> past postcode.

2. A screen will be displayed showing all the addresses which match that postcode.

3. Scroll through the list using the page down and/or down arrow key until the one you require

is highlighted.

4. When the correct one is highlighted, press <Enter> to enter the address.


Option 3 – Searching using house name and town

1. Enter the house name followed by a comma and the name of the town.

e.g. Meadowlands, Waterlooville, and then press <Enter> past postcode.


Option 4 – Searching using street name and town

1. Enter the name of the street followed by a comma and the name of the town,

e.g. Langstone Road, Portsmouth, then press <Enter> past postcode

2. A screen will be displayed showing all the addresses which match that postcode.

3. Scroll through the list using the page down and/or down arrow key until the one you require

is highlighted.





Option 5 – Searching using house number and street name

1. Enter the house number followed by a space followed by the name of the street,

e.g. 96 Langstone Road, then press <Enter>past postcode.

2. A screen will be displayed showing all the towns, which have a street of that name.

3. Scroll through the list using the page down and/or down arrow key until the town you require

is highlighted.



Option 6 – Searching using whole address without postcode.

1. Enter address as usual, press <Enter> to Postcode field, press <Enter> and the postcode for

the address will appear.


Option 7 – Military Addresses

1. Press Key F9 (Superhelp). Enter name of barracks / regiment or base followed by name of

town, e.g.

H M S Collingwood, Fareham (H[space]M[space]S[space])

Royal Air Force, Farnborough

Royal Army Medical Corps, Aldershot

Roberts Barracks, Salisbury

Ministry of Defence, (name of town if known)

At Sea/In the Air this gives pseudo postcode - up arrow and type in the correct address e.g.

H M S INVINCIBLE, followed by BFPO No. (If known).

NOTE: BFPO gives nothing if this is the only info entered.

2. Press <Enter> to enter the address. The complete address will be entered for you – check

that this is correct.

NOTE: It will not always be easy to find military addresses. Do your best, if you cannot find the

postcode address, type in all you know in the bottom box and leave the postcode field empty, but

you MUST complete the missing postcode form (Page 24).



Option 8 – Foreign Countries

There are two ways of searching for addresses outside the UK.

1. Type in name of country, e.g. France.

2. Press <Enter> through the Postcode field and the postcode will appear.

3. Arrow back up to top of the Extended Address box and type in the full address.

Or

1. Press <Enter> until you reach postcode.

2. Press Key F9 (Superhelp).

3. Enter name of country.

4. Press <Enter> to accept postcode.

5. Arrow back up to the top of the Extended Address box and type in the address.

Option 9 – No Fixed Abode

1. Type: NO FIXED ABODE.

2. Press <Enter> through the Postcode field and the postcode will appear.


NOTE: If there is an existing postcode from a previous address you must delete it using the F2 key

to ensure the no fixed abode postcode is entered.

14.2. Other Tips

The + symbol at the side of an address means there is additional information available.

For example if you highlight and then press <Enter> on:

+ Without building name, Oxford Road, Gerrards Cross

the following would be displayed:

SL9 7DP French Horn, Oxford Road, Gerrards Cross

SL9 7DP One Stop Community Store, Oxford Road, Gerrards Cross

It is also possible to use the symbol * at the end of your search criteria to increase the area of your

search.

For example Nursery* would find: Nursery Gardens, Nursery Close, Nursery Road, etc.

If your search criteria is unsuccessful, hit Previous Field Key (F6) and try a different search.

If amending details on the front screen, but not the address field “Page Down” will move you quickly

through the address fields.

If the auto postcoder cannot find an address with your spelling it may provide an alternative TAKE

CARE – it may not be the correct address.



15. FAULT REPORTING

From time to time you may experience problems with faulty equipment, software problems or access

to the Patient Administration System (PAS) i.e. password non acceptance problems. To resolve your

problem a call with need to be logged with the ICT Service Desk.

15.1. ICT Service Desk

Email [email protected]

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 Asset 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.

15.2. Out of office hours

Contact 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.

15.3. ICT Training

If 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 [email protected]

External Phone 023 9228 6000

Internal Phone QAH (7700) 5867

16. 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.





17. 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, April 2014



18. VERSION CONTROL/LOG

Manual PMI Add and Revise

Version V 4.3

Date Feb 2013

Revisions Page

Update Information Governance 2 & 3


Version V 4.23

Date 17th February 2012

Revisions Page

New None

Updated MPAC Address to: MDHU Portsmouth, Albert House, Queen

Alexandra Hospital, Cosham, PO6 3LY. Verified by MDHU.

8


Version V 4.22

Date July 2011

Revisions Page

New None

Updated Added new header and footer to document and repaginated.

Updated Information Governance document.

Updated candidates appeal procedure.

All

5 & 6

33


patient master index · 5. add new patient details the following procedure should only be used if...

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