Tracing, Recording and Using NHS Number Policy & Procedure

Transcription

1 SH IG 44 Tracing, Recording and Using NHS Number Policy & Procedure Summary: This policy and procedure applies to all Southern Health NHS Foundation Trust teams and services. It relates to clients/patients who are registered as receiving a service, either currently or whose episodes of care have been discharged or closed. National Information Governance standards require the Trust to ensure that the NHS number is routinely collected for every current patient and it is used routinely in clinical correspondence both internally (e.g. for associating test results with a patient's clinical/care record) and collaboratively with external organisations Keywords (minimum of 5): (To assist policy search engine) This policy is written with reference to the Trust s Information Security Policy. NHS Number, RiO, OpenRiO, Community, Child Health, Quit 4 Life, CaMIS, ecamis, Tracing, NNN, SCR Target Audience: All Team Managers, Administrative and Clinical Staff who register or update client records on Client Information Systems Next Review Date: August 2017 Approved & Ratified by: Information Governance Group (virtual) Date 07/08/2015 Date issued: Author: System Support Team Manager (Lisa Crome) Sponsor: Associate Director of Technology (Helen Reading) 1

2 Version Control Change Record Date Author Version Page Reason for Change 30/09/2014 Lisa Crome V2 All Review and update minor changes 28/07/2015 Lesley V3 All Review and update. Barrington 30/7/2015 Lisa Crome V3 All Review and update minor changes Reviewers/contributors Name Position Version Reviewed & Date Information Governance Group IGG membership 13/05/2013 Information Governance Group IGG membership Virtual approval 30/09/2014 Information Governance Group IGG membership Virtual approval 07/08/2015 2

3 Contents Page 1. Scope 4 2. Purpose 4 3. Duties/ responsibilities 4 4. Background 4 5. Purpose of Procedure 5 6. Who will use Procedure 6 7. Relevant Data Definitions 6 8. Process to be followed 6 9. Untraceable and Duplicate NHS Numbers Monitoring process and Data Quality Report Batch Tracing Associated Policies and Procedures Procedure for on line Tracing 8 3

4 Tracing, Recording and Using NHS Number Policy & Procedure 1. Scope: This policy and procedure applies to all Southern Health NHS Foundation Trust teams and services. It relates to service users who are registered as receiving a service, either currently or whose episodes of care have been discharged/closed. At least 95% of records of active patients must have an NHS number traced and verified. This policy reflects current practice for Tracing, Recording and use of client NHS Number - and will be reviewed as soon as new information systems are implemented across the trust. 2. Purpose: This policy is designed to enable electronic systems to be kept up-to-date with accurate service user held information, and to ensure the appropriate archiving and destruction of manual/paper health records. It aims to: avoid information being sent to incorrect service users and their families; comply with Data Protection Act 1998; comply with Information Governance requirements for the documentation of accurate and timely data. There is consistent and comprehensive use of the NHS number in line with National Patient Safety Agency requirements IGTK Responsibilities: It is the responsibility of all staff (including administrative, clinical/practitioners and support staff) to ensure that they maintain accurate and up-to-date information on both electronic and paper records systems. If a staff member is aware that a service user record does not hold the NHS number, they should follow the procedures set out below. 4. Background National Information Governance standards require the trust to ensure that the NHS number is routinely collected for every current patient and it is used routinely in clinical correspondence both internally (e.g. for associating test results with a patient's clinical/care record) and collaboratively with external organisations Southern Health NHS Foundation Trust has implemented Spine enabled Patient Information Systems in conjunction with Connecting for Health Programme, which is now covered by the Health & Social Care Information Centre (HSCIC). This programme has enabled over 99% of client records OpenRiO (Electronic Patient Record) to be registered with NHS Number. User of spine enabled systems must 4

5 follow the system training given and Standard Operating procedures / Handbook available in the OpenRiO pages of Trust Intranet. Users on non-spine enabled systems must follow the system training given, and if necessary perform additional manual trace for client NHS number. It is important that the Service User NHS Number is used on all clinical correspondence as an additional tool to ensure that clinical information is linked to the correct Service User. Failure to do so will potentially place Service Users at risk and does not meet the Trust s governance requirements. Tracing Service User NHS Numbers will reduce and/or identify duplicate records on systems. NHS Number trace identifies previous known addresses, previous names and aliases. This should enable on-line tracers to identify where possible duplicates have been made on Trust systems. Other Patient Information Systems that are not spine enabled have a monthly batch tracing procedure for updating client records with a present and verified NHS Number status, or rely on manual tracing. Audit of these systems show a NHS Number capture of over 98%. Manual Tracing can be performed where Client NHS number cannot be traced using the search functionality in spine enabled systems or by batch tracing process. The NHS Spine Application, Summary Care Record (SCR) is populated with records using the NHS number as the unique identifier. The Information Quality Assurance Programme (IQAP) has reinforced this, and in the interests of preserving the integrity of patient records shared and accessed nationally. The NHS Spine Application, Summary Care Record (SCR) is a national database of people, places and organisations. NHS staff, who are subject to stringent security procedures, are able to access their Client details to obtain their NHS Number and a range of up-to-date administrative information eg confirmation of address and registered GP. The trust is committed to ensuring that the use of NHS number is maximised through: Spine Enabled Patient Information Systems Use of batch tracing on all patient systems Regular use of on line tracing where NHS number has not been provided by referrers And will support staff through: Provision of training on the use of NHS number on line tracing Audit of the use of NHS numbers 5. Purpose of the Procedure Ensure spine enabled systems tracing procedure before registering a client record 5

6 Ensure that batch tracing of NHS Numbers through NHS Spine Application, Summary Care Record (SCR) is carried out systematically via the Trust s Service User Management systems. Ensure that on-line tracing is utilised for tracing NHS Numbers for current Service Users that have not been traced by batch tracing. Ensure that collection and recording of Service User NHS Number is conducted in a robust manner. 6. Who will use the procedure? Nominated administrative staff in all teams where Service User Information is collected and recorded have been identified and trained in using the NHS Spine System, SCR. The System Support Team and some information analyst staff are trained for on-line tracing. On line tracing can be used to manually upload Service User information on any Patient administration system used by the Trust. This is in addition to the systems that have a batch upload via ICT Services. 7. Relevant Data Definitions The NHS Data Dictionary defines the NHS Number as a number used to identify a person uniquely within the NHS in England and Wales. 8. Process to be followed The SCR is only to be used for checking Service User information it cannot under any circumstances be used to check private information. Access to SCR is mostly through smartcard, however if staff access with Passwords these must be kept secure and not divulged to anyone else. All person identifiable information must be kept confidential and only disclosed to other members of staff who have a need to know in the course of their work. Access to NHS Spine Application, Summary Care Record (SCR) The Caldicott Guardian has endorsed procedures to allow nominated staff to use SCR to manually trace client NHS numbers. All staff nominated to be users of SCR will have appropriate RA roles added to their Smartcard to allow access to any NHS Spine Application. All applications will follow the Role Based Access Code (RBAC) process for sponsoring and issuing of Smartcards. Team Managers will identify those staff to be trained in on-line tracing for Service User NHS Number 6

7 9. Untraceable and Duplicate NHS Numbers There are some Service Users NHS Numbers which cannot be traced. This may be because: The person has not changed their GP, or address for many years The person has been in long term Inpatient care The person has been in prison for a length of time The person is, or has recently been in the armed forces The person is an asylum seeker, currently in a detention centre The person is not registered with a GP Obtaining NHS Numbers for those people not on the SCR system. If a Service User cannot be found / traced on SCR, then contact should be made with the GP Practice to enquire if they know the NHS Number of the Service User. If they do not, ask if the client has been registered with the GP Surgery. It will take approximately 6 weeks for a person to appear within the SCR system. System users can log a call with their Service Desk asking for assistance from System Support Team to trace individual clients. If client NHS is found SST will update and synchronise client record if appropriate, or will advise user of client NHS number. In some cases SST will create an NHS number on the spine for a client. If an SCR user finds data quality issues such as duplicate entries on SCR or incorrect patient information, they are to log a call with their Service Desk who will assign the call to System Support Team. System Support Team will log a call with the National Back Office Service Desk. 10. Monitoring process and Data Quality reports The Information Manager will be responsible for reports developed by information staff to monitor NHS Number capture across the Trust eg Overall performance edqrs (electronic data quality reporting system) reports Recent discharges to pinpoint inpatient areas where NHS numbers are missing (and on-line trace) 11. Batch Tracing Batch Tracing for systems not managed to SHFT is undertaken on behalf of the Trust by Service System Frequency of Batch Tracing UHS, ICT Services CaMIS / ecamis Submission for batch upload sent every two weeks 7

8 12. Associated policies and procedures Southern Health NHS Foundation Policies & Procedures are in place to help and guide staff in the capture and use of Patient Identifiable Information. All Policies and Procedures are available on Trust website 13. Procedure for on-line Tracing The function of the Spine Portal is to provide a single, secure point of entry to a number of applications being provided as part of the NHS Care Records Service. System user will access SCR from their PC Icon and software to connect to Spine Applications will have been installed by the users local ICT Provider. All users will have a Spine Application Smartcard issued to them (under Role Based Access procedures) which will enable them to access SCR at the level agreed by their Managers. The Spine Portal To Log on to the Spine Portal Insert your Smartcard into the card reader. The system will check the credentials of the Smartcard and then request you to enter your Passcode. Figure 1 - Log on to the Spine Portal - Passcode required Enter your Passcode. If you have more than one job role, click the session role hyperlink you wish to use. 8

9 Figure 2 - Log on to the Spine Portal - Select your session role Note: If you only have one job role the job role selection screen will not appear. The following message will be displayed to confirm your name, organisation and job role, this will disappear after a few seconds. Figure 3 - Log on to the Spine Portal - You are logged on as You are now logged on to the Spine Portal. Open the Portal through any desktop shortcuts. To Log off the Spine Portal To log off the system, you simply remove your Smartcard from the card reader. Removal of the Smartcard will log you out of the Spine, its applications and the Spine Portal. Warning: Simply removing your Smartcard may close any open Browser windows without warning and unsaved data may be lost. This may include Browser sessions that have been launched from outside of the Spine Portal. This depends on local configuration of your system. Person tracing A full training document is available on HSCIC website: Search?q=NHS+number&go=Go&area=both 9

10 Recording NHS number to patient information systems To copy NHS Number to SHFT Patient Information System, click on the NHS Number, click copy and paste into SHFT system. It has been noted that some systems do not allow NHS number to be pasted, users will therefore have to make note of number, and type into SHFT system, ensuring that correct number has been noted, and typed. Whenever possible use the cut and paste option to minimise errors 10