Procedure for the Identification and
Resolution of Duplicate or Inaccurate
Patient Records on PAS
Classification: Procedure
Lead Author: Gill Cartledge, Head of Clinical Coding &
Data Quality
Additional author(s): Jonanthon Bremmer, Data
Quality Manager
Authors Division: IM&T
Unique ID: HRE1(08)
Issue number: V8.0
Expiry Date: July 2017
Contents
1
2
Section
Page
Who should read this document?
Key Points
What is new in this version?
Policy/Procedure/Guideline
Standards
Explanation of Terms/Definitions
References and Supporting Documents
Roles and Responsibilities
Protocol – Identifying Duplicate Records
Protocol – Investigating Duplicate Records
Protocol – Merging Duplicate Records
Protocol – Confused Records
Monitoring and Review
Appendix
Appendix 1 – Microfilm Front-sheet
Appendix 2 – Example Monitoring Information
2
2
2
2
2
3
3
3
3
5
6
7
8
9
10
Document control information (Published as separate document)
Document Control
Policy Implementation Plan
Monitoring and Review
Endorsement
Equality analysis
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Procedure for the Identification and Resolution of Duplicate or
Inaccurate Patient Records on PAS
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10
11
12
12
13
Who should read this document?
This document is required reading for all PAS users within the Trust.
Key Points
This policy details the requirements and work processes to ensure that PAS
records remain accurate and contemporaneous.
What is new in this version?
Revision to the processing of records for potential overseas visitors.
Revision to the process for submitting ‘National Back Office’ queries.
Additional section regarding confused records
Policy
This procedure must be adhered to in order that the Trust may achieve
Attainment Level three of the Information Governance Toolkit Requirement
402.
The Trust ensures that duplicate or incomplete/inaccurate records and the
associated health records are resolved or corrected as soon as possible. It
has methodologies and/or systems in place to prevent the creation of such
records in the Master Patient Index and to regularly monitor timescales for
resolution and rates of occurrence. Corrective action is taken to ensure
occurrence rates of duplication, confusion etc. are minimised.
Standards
Formally documented procedures for the identification and resolution of
duplicate or confused/overlaid patient records.
Minutes of board, or delegated sub-group meeting showing approval and signoff.
Evidence that records have been merged/unmerged in a timely fashion.
Documented methodology and/or system to prevent the creation of duplicate
or confused/overlaid records.
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Procedure for the Identification and Resolution of Duplicate or
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Explanation of terms & Definitions
DBS
DQ
EPR
HSCIC
NSTS
OSV
PAS
SCR
Demographic Batch Service
Data Quality
Electronic Patient Record
Health and Social Care Information Centre
National Strategic Tracing Service
Overseas Visitor
Patient Administration System
Summary Care Record
References and Supporting Documents
All information Governance Policies,
Data Protection Act,
Information Security Management:
NHS Code of Practice,
Risk Assessment and Risk Register Policy
Roles and responsibilities
Roles and Responsibilities:
The Data Quality Team is responsible for identifying and monitoring all
duplicate or confused/overlaid patient records.
The Data Quality Team is responsible for ensuring duplicate records are
merged in a timely manner.
The Electronic Patient Record is automatically updated when a merge is
completed in PAS. However in some instances this doesn’t happen, in these
cases the patient details appear on an error report which then initiates a
manual update of the records in EPR to complete the merge.
The EPR Team (Development/Interfaces) is responsible for the completion of
a manual update of records in the EPR system where this is required.
Protocol
Identifying Duplicate Records
On a regular basis (weekly) a routine batch trace is performed using the
HSCIC Demographics Batch Service (DBS) to facilitate the identification of
duplicate records.
The routine DBS batch trace also assists in the
identification of deceased patients whose deaths have not yet been registered
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Procedure for the Identification and Resolution of Duplicate or
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locally and records with missing NHS numbers for further review. A separate
procedure details the steps involved in running the routine DBS batch trace
(see Data Quality local procedures and policies available through the Data
Quality SharePoint page for details on generating a file for tracing in PAS,
submitting the file through the DBS client, retrieving and uploading the
response back into the PAS system).
Daily monitoring of current inpatients is also undertaken by the Data Quality
Team several times a day during the week between the hours of 08:00 and
16:00. The Data Quality Team acts on notification from departments in the
hospital via email and telephone calls regarding duplicate patient registrations.
To enable all records to go through a DBS trace the records need to be
updated as follows:Current Inpatients
Contact the ward clerk or ward staff member and ask her / him to
update PAS with the missing demographic data. Daily monitoring is
carried out between 08:00 and 16:00 during the week day, at each time
of monitoring if the record has not been updated then on the third
occasion the ward manager is notified to ensure this request is carried
out. National Spine access is utilised by the Data Quality Team if the
ward staff can not update the demographics.
Overseas Visitors
A member of the Data Quality Team contacts a representative of the
Overseas Visitor (OSV) Team via telephone or email if a patient has no
GP, no NHS number or has registered with a GP in the last six month
so that the patient can be interviewed by the Overseas Visitors Team if
required. The patient details are added to a database of potential
overseas visitors (to enable issue tracking and to minimise repeat
notification).
Following the introduction of the Health Surcharge for non-EEA
nationals from April 6th 2015 additional information will become
available through the NHS Summary Care Record (SCR) (‘the Spine’).
Individuals who have paid or are exempt from paying the surcharge will
have a green banner on their Summary Care Record, whilst those who
are likely chargeable for NHS services will have a record which
displays a red banner. This information will also be passed by the Data
Quality Team to the OSV team where it becomes available in the
course of Data Quality assurance checks.
Unidentified Patients
The A&E Department may create duplicate records when the patient is
unidentified on admission or refuses to give their details. These
patients are identified on PAS as per the majax policy and the
admission date is recorded as their date of birth. Once identified the
correct details will be recorded on PAS and Unknown will remain as a
previous surname until an NHS Number has been allocated or the
record is merged.
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Should the correct identification details for an unknown patient be
determined the existing demographic information (name and date of
birth) on the PAS system should not be revised until the patient is in a
more stable environment (i.e. a ward or other non-emergency care
area).
DBS Batch Tracing
Weekly the Data Quality Team will submit a file to DBS to obtain/verify
the NHS Numbers which are then loaded back onto PAS for
subsequent analysis and processing. This process was introduced in
2009 and replaces the National Strategic Tracing Service (NSTS).
Investigating Duplicate Records
The patient demographic details are investigated for each new duplicate
record identified and the following procedure is followed:Where a new registration has been created with exact details the
source of admission needs to be checked to ensure the patient was not
originally registered as an ‘unknown’. If the registration was due to the
user not carrying out an accurate search in PAS a transaction log will
be run to identify the person who has re-registered the patient. Details
will be recorded in the Data Quality merge database and the user will
be contacted by the Data Quality Team and a member of the Training
team and informed of the error.
Trust staff should be operating in accordance with the Patient
Identification Policy to ensure that patients are correctly and positively
identified, that records are kept up-to-date and accurate and to prevent
the duplication or confusion of existing patient records and any
resulting risk or harm that may result from it.
Duplicate records with an old address on one of the registrations will be
checked on national spines and PAS amended by Data Quality with the
current details.
All other duplicate registrations will be checked by a member of the
Data Quality Team and discrepancies in dates of birth, spelling of
names etc. will be checked with the National Spine Portal, the GP, or if
necessary, the patient is contacted to ensure the correct details are
recorded on PAS. Details will be amended on PAS by Data Quality.
Any NHS number conflicts will be double checked and verified by 2
members of the Data Quality Team before changes are authorised.
Where incorrect data is recorded on the National Spine Portal this will
be reported to the HSCIC SSD National Service Desk through their
Weblog Portal at http://nww.nhscfhservicedesk.nhs.uk/ which has
superceded the ‘National Back Office’ form which was previously
completed and submitted for investigation. A user account is needed
to submit requests via the Weblog Portal. Staff who do not already hold
an
account
can
request
one
by
emailing
[email protected].
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Procedure for the Identification and Resolution of Duplicate or
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Further duplicate records may be identified when tracing patients who
have failed the DBS search as these patients have provided the Trust
with different demographic details to those the GP has. Again the
patient/GP may be contacted to confirm details by a member of the
Data Quality Team.
The Patient Administration System does not allow users to input an
NHS Number if it has already been allocated to another record. This
ensures that patients cannot be registered more than once with their
NHS Number recorded unless Choose and Book has created them
which can often create two identical NHS numbers. It is therefore
important that a search on the NHS Number is made if the patient
cannot be found during the name search.
If a duplicate record has been created and the patient is currently an
inpatient the Data Quality Team will check the old record for recent
episodes. If there is a recent episode on the old number the Data
Quality Team will check on EPR for current Orders and the following
steps will be taken:No Orders
The ward will be contacted and given details of the old record.
The Data Quality Team will delete the admission and add the
admission under the old record. The ward will arrange for any
correspondence in the new case notes to be transferred to the
old case notes and Data Quality will merge the records together
retaining the old number.
Orders
The ward will be contacted and given details of the old record.
Both sets of notes available to the ward. The notes should be
returned to Data Quality on discharge and merge will be
completed. EPR team will be informed.
Merging Duplicate Records
Data Quality will request the retrieval of physical casenotes from the Health
Records Department. A member of the Data Quality Team will attend the
main site Health Records Department to perform merges of physical case
notes within a month of the casenotes being retrieved or when the number of
records casenotes retrieved reaches ten (whichever is soonest).
Merges should be performed on the main site to reduce the risk of information
security or governance issues of transporting casenotes off-site (the Data
Quality Department is situated in premises that are not on the main hospital
site).
Where two sets of case notes exist for a merge, these will be physically
amalgamated and the merge recorded on PAS in line with PAS procedure.
Some PAS registrations may not have a case note issued, in which case only
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Procedure for the Identification and Resolution of Duplicate or
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the registrations will need to be merged. The merge Database is updated by a
member of the Data Quality Staff.
Via PAS, the Data Quality Clerk withdraws the appropriate Hospital Number.
This will usually be the newest number with the following exceptions: 
Where the old number does not have any episodes attached, but
the new number does.

For urgent inpatient merges the number used for ordering must be
retained.
In the case of previously microfilmed case notes, the microfilmed number
MUST be retained and newer numbers merged into the microfilmed number.
Prior to withdrawing the newer number the following must have occurred:
i.
Update any details on either number
ii.
Print off labels to be retained and update case note cover
accordingly
iii.
Perform PAS merge
iv.
Insert a physical copy of Microfilm Request Form in front of
retained physical case notes. This form can be completed
electronically and submitted to the Scanning Bureau for
inclusion in the scanned record (Appendix 1).
If one set of case notes cannot be located for a merge to take place, the
Health Records Supervisor and Data Quality Manager should be contacted. A
decision will be made whether the merge should go ahead, i.e. if there is little
possibility of locating the missing records. All efforts will be made to
concentrate on merges where all sets of case notes are available. However,
in instances where one set of case notes cannot be located, the Data Quality
Manager should be contacted for advice and the following will occur after six
months.
Merge will be recorded on PAS and the fact that case notes are missing will
be in the merge database.
i.
Merge will be recorded in located case notes using the attached
alert sheet
ii.
A search for the missing case notes will continue until located.
iii.
PAS and Duplicates Database to be updated with details.
Following completion of the physical merge of case notes, PAS tracking
should take place in line with Health Records policy. The merge Database is
updated by the Data Quality staff.
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Procedure for the Identification and Resolution of Duplicate or
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Confused Records
A related issue is the occurrence of confused or overlaid patients records,
where information from the records of two distinct patient records has been
combined either in full or part.
Confused/overlaid records can be created as a result of inappropriately
merging patient records. Where this occurs an investigation should be
conducted by the Data Quality Manager or Head of Clinical Coding and Data
Quality to identify the root cause, to ensure existing practice guidelines have
been followed and to consider reviewing departmental procedure if
appropriate.
Record confusion can be compounded in instances where incorrect details
(e.g. the wrong patient’s NHS number) are provided on referral documentation
received by the Trust.
Staff should be mindful of this when
checking/reviewing documentation prepared by other organisation.
There may be instances were orders or investigations are created against an
incorrect patient record (an admission being created using the wrong hospital
ID as a result of failing to observe the Patient Identification Policy for
example). In these cases, as well as ensuring the EPR record is corrected by
the EPR team and the activity is recorded on the appropriate record in
PAS/Patient Centre a member of the data quality team should also inform
contacts within the Pharmacy, Radiology/PACS and Pathology departments in
order that the data quality of respective local systems (Ascribe, CRIS and
Telepath) can also be reviewed and revised where necessary.
Area
Information System
Contact
Extension
Pharmacy
Ascribe
Stephen Bewley
65919
Pathology
Telepath
Colin Garside
68006
Radiology/PACS
CRIS
James Carruth
64936
Recommended contact information as at 16/07/2015, refer to online Staff Directory for latest
information.
Monitoring and Review
Once a registration has been identified as a duplicate, details of duplicate
registrations are recorded in a database by the Data Quality Team with the
date the merge takes place.
On a weekly and monthly basis a file is submitted to DBS (demographic batch
service) to identify the outstanding number of duplicate records. The
outstanding number is recorded in a graph which is reviewed internally by the
Data Quality Team and reported at monthly Management Information Steering
Group (MISG) meetings (See appendix 2 for an example).
To ensure records are merged in a timely manner. This will be monitored by
the Data Quality Manager.
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Procedure for the Identification and Resolution of Duplicate or
Inaccurate Patient Records on PAS
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Appendices
Appendix 1 – Microfilm Request Form
SALFORD ROYAL NHS FOUNDATION TRUST
Health Records Department
Patient name
Hospital number
Batch number
Date requested
Department
Roll number
Extension
A copy of the microfilmed record can normally be made available within 48
hours of request (Monday – Friday; 08.30 – 17.00 hours)
Urgent requests will receive immediate response during the working week.
We ask that microfilmed files are viewed and NOT printed whenever possible.
In the case of an emergency, requests can be made out-of-hours, as follows:
Saturday and Sunday 08.30 – 12.00 hours
The out-of-hours service will respond as quickly as possible, but this may not
be immediate. Please leave a message on the answer phone if necessary.
To request a copy of the microfilmed record, please complete microfilm form
available with the Health Records Department, quoting the patient name,
hospital number and microfilm roll number.
Health Records Library (ext 64805)
Reprinting information:
Correspondence only printed (initials of clerk)
Whole record printed (initials of clerk)
Date
Date
.
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Inaccurate Patient Records on PAS
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Appendix 2 – Example of Merge/Duplicate Monitoring Information
The following is an example of merge/duplicate monitoring information which
is summarised and included in the Data Quality briefing paper produced for
monthly Management Information Steering Group (MISG) meetings:
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Procedure for the Identification and Resolution of Duplicate or
Inaccurate Patient Records on PAS
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Issue 8.0
October 2015
Procedure for the Identification and Resolution of Duplicate or
Inaccurate Patient Records on PAS
Current Version is held on the Intranet
Check with Intranet that this printed copy is the latest issue
Page 11 of 11