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
Further Guidance/Information
Head of Information (policy issues)
Ext 62009
Deputy Director of Operations
Nottingham University Hospitals NHS trust
Information Services
Patient Demographic Information Validation Policy
Contents
Paragraph
Title
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
Appendix B
Equality Impact Assessment Report
13
Appendix C
Employee Record of having Read the Policy
15
Nottingham University Hospitals NHS Trust
Information Services
Patient Demographic Information Validation Policy
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2
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.
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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Patient Demographic Information Validation Policy
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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:





2.3
Patient Data Quality Policy
Health Records Management Policy
Health Records Keeping Policy
Information Security & Data Protection Policy
Information Governance Policy
This policy is a statement of intent which members of staff are
expected to follow and should be regarded as mandatory by all
staff. Failure to follow a trust policy could result in disciplinary
action being taken, up to and including dismissal.
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Patient Demographic Information Validation Policy
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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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Patient Demographic Information Validation Policy
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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
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
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 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
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.
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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.
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
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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) system
https://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.
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.a
spx
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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 DeMerges for detailed procedure:
http://nuhnet/nuh_documents/Documents/Duplicate%20Registratio
ns,%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.
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.
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13.0 Reference Information
The 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 system
Within 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
patients who live in the Nottingham area.
NHS Summary Care
Holds demographic information on
Record (SCR)
patients for the whole country. This can
Demographic Batch Tracing be accessed via:
Service (DBS)
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
Royal Mail Postcode reference books,
Books
located in Data Quality Offices.
Nursing Homes Directory
A manually compiled directory of local
Nursing homes, located in Data Quality.
Directory of family Doctors Compiled by Nottingham Family Health
and their services
Services Authority, located in Data
Quality.
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Appendix A
Dummy G.P Codes
The 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 Code
Unknown G.P
G9999998
UNKNOWN
Prison Doctors
P9999981
MED
Armed Forces
A9999998
MOD
G9999981
REG
(Services)
No Registered G.P
Glossary
CMDS
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 Basics
(b) TotalCARE PAS Training & User Guides
(c) THI User Manual
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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
6.
Brief Summary of Research and Relevant Data
7.
Methods and Outcome of Consultation
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8.
9.
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
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
N/A
11.
Monitoring and Review Arrangements
This policy and associated documents should follow the NUH
guidelines for monitoring and review once implemented.
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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
Nottingham University Hospitals NHS Trust
Information Services
Patient Demographic Information Validation Policy
SIGNATURE
DATE
15