Inpatient Clinics (IPC)

Transcription

1 Patient Administration System Inpatient Clinics (IPC) Pre Admission Level 4 Version 1.2 August 2011 IT Training Ground Floor Rodney Road Centre (SMH) PO4 8SY Tel: it.training@porthosp.nhs.uk Website: IT 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. IT 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 IT Training website. All references made to patient records are fictitious for the purpose of training only. Inpatient Clinics (IPC) VN1.2

2 CONTENTS 1. GENERAL COURSE INFORMATION INFORMATION GOVERNANCE What can you do to make Information Governance a success? CONFIRMATION OF DETAILS PROCEDURES INTRODUCTION TO INPATIENT CLINICS Booking from Waiting List Booking from Preadmission APPOINTMENTS Waiting List & Pre-Admission Cancellations & Inpatient Appointments RECORDING AN INPATIENT APPOINTMENT <FBA> Inpatient Appointment View <EPI> APE -Inpatient Appointment View REVISING APPOINTMENT DETAILS <REA> CANCELS ON THE DAY OR DID NOT ATTEND <CND> <DNA> CANCELLATION OF A FUTURE APPOINTMENT <CAP> EPI Cancelled Appointment View CANCEL & REBOOKING AN APPOINTMENT <CAB> Cancelled & Rebooked View <EPI> CANCELLED & REBOOKED VIEW <APE> REINSTATE A CANCELLED INPATIENT APPOINTMENT <RCA> TOA RECORD PAST APPOINTMENT/ WALK-INS REPORTS Inpatient Diary Reports <IDR> Inpatient Diary Dump <IDD> Inpatient Pulling List <IPL> UCI IP Unrecorded Clinic Attendance Report RECORD ATTENDANCE & DISPOSAL <AAD> DNA Follow Up <DFU> INPATIENT CLINIC ENQUIRY FUNCTIONS Clinic Booking Summary <CBK> Clinic Enquiry <CEQ> Cancel Suspend Clinic Enquiry <SCE> Inpatient Clinics (IPC) VN1.2

3 17. SHORT CUT CODES FAULT REPORTING IT Service Desk Out of office hours IT Training HELP WITH USING PAS IT TRAINING CANDIDATE APPEALS PROCEDURE VERSION CONTROL/LOG Inpatient Clinics (IPC) VN1.2

4 Patient Administration System (P.A.S) Course 1. GENERAL COURSE INFORMATION COURSE TITLE METHOD OF TRAINING DURATION PRE-REQUISITES INPATIENT CLINICS <PRE4> Classroom 5 hours PMI Add & Revise, Waiting List and Pre-Admission Level 3 or Outpatient Module 5 ABOUT THE COURSE Attending this course will enable the student to record and manage Inpatient Pre Op Assessment appointment activity using PAS, in accordance with Trust requirements and Information Governance regulations. SUITABLE FOR Ward staff Clerical and Clinical OBJECTIVES This course will enable the student to: 1. Book an inpatient appointment to a Waiting List or Pre Admission episode. 2. Distinguish between Outpatient and Inpatient appointments. 3. Revise and delete appointments. 4. Cancel, rebook and reinstate cancelled appointments and be aware of the implications of these actions regarding Waiting List and Pre Admission activity. 5. Record the outcomes of appointments. 6. Follow procedure of recording action taken after a Did Not Attend (DNA) or a Cancel on the Day (CND) appointment. 7. Record appointments that happened in the past. 8. Use enquiry functions to assist with the management of inpatient clinics. 9. Use the Inpatient Reporting facility to help assist and manage the effectiveness of Inpatient appointment recording. Inpatient Clinics (IPC) VN2.3 1

5 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 about patients/clients and employees, in particular, personal and sensitive information. It 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) Further information can be accessed through the Trust Intranet: Information Governance (Departments sections), and Management Policies (Policies section) 2.1. What can you do to make Information Governance a success? Keep personal information secure Ensure confidential information is not unlawfully or inappropriately accessed. Comply with the Trust IT 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 s, secure postal or fax methods) 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 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 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. Inpatient Clinics (IPC) VN2.3 2

6 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 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 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. For further Information Governance training refer to: Written by PHT Information Governance Manager, Sept 2010 Inpatient Clinics (IPC) VN2.3 3

7 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 (eg 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: IT 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 Inpatient Clinics (IPC) VN2.3 4

8 4. INTRODUCTION TO INPATIENT CLINICS Inpatient Clinics are a way of recording patient activity for Pre-op assessment appointments. At present these have either been recorded as Outpatient Appointments, Ward Attenders or manually in diaries. It is now possible to book an inpatient appointment from either a Waiting List episode or a Preadmission episode. If a clinic for consultant (a) is selected to book to a Waiting List/Preadmission episode for consultant (b) the system with give a warning message but it is possible to continue. When making an inpatient appointment the operation comment, if completed, will come through to the appointment comment, it can be overwritten or deleted if necessary. Appointment has fields Patient s Choice and Booking Type, these fields are not mandatory, but the information is required for stats. Appointment can be viewed in EPI and APE and shows as Department Inpatients. If the appointment has been booked via a Preadmission the TCI date can be viewed. Cancellation of appointments can also be viewed 4.1. Booking from Waiting List It is possible to book an inpatient appointment if patient only has a waiting list episode. Once an appointment has been booked, if removal from the waiting list is attempted the system will prevent user from doing so as there is an appointment in the future. User would need to cancel appointment, and then remove from waiting list. If this has been done in error user would need to delete waiting list removal and then reinstate cancelled appointment Booking from Preadmission If the appointment is booked to the preadmission episode the TCI date will appear in the appointment details in EPI and APE If the preadmission is cancelled the inpatient appointment is also cancelled by the system. The appointment cancellation details show as Reason Text: Preadmission Cancellation CNC HC. If the cancellation is deleted (delete outcome) the appointment is automatically reinstated. If the preadmission is cancelled and rebooked, the appointment is cancelled, even if the TCI date is brought forward. Users need to be aware of this and can Reinstate the cancelled appointment if this is appropriate. Inpatient Clinic reports appears to work same as Outpatients. Doctor report does not show TCI date. Inpatient Clinics (IPC) VN2.3 5

9 5. APPOINTMENTS 5.1. Waiting List & Pre-Admission Cancellations & Inpatient Appointments. If a WL or PRE episode is cancelled the inpatient appointment will automatically be cancelled too. If this is still required, the appointment can be reinstated using the function of RCA. BE AWARE OF ANY IMPLICATIONS YOUR ACTIONS MIGHT MAKE. Inpatient Clinics (IPC) VN2.3 6

10 6. RECORDING AN INPATIENT APPOINTMENT <FBA> 1. LIS - Search for your Patient in the recommended way, check that all demographic details are correct & that the patient has a current Case Note number. 2. Select FBA - record changes to your patients details (if required) & make the patients inpatient appointment. 3. Select the correct episode of care to attach the patient s appointment to. You are looking for the Waiting List or Pre-Admission Episode for the relevant Consultant/Speciality. 4. After selecting the appropriate episode the Appointment Details Screen will be displayed. Check the appointment: a) Has not been previously booked OR b) Conflicts with any other booked hospital appointment. 5. Enter the relevant Clinic Title (F9) Enter the Appt Type (F9) Enter Date/Time of appt. 6. Select the appointment from the Doctor Timeslot Display Screen & complete the Selected Appointment Details Screen. Inpatient Clinics (IPC) VN2.3 7

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12 6.1. Inpatient Appointment View <EPI> 1. Find your Patient & relevant Episode of Care. 2. Press Return at the Display Inpatient Events Screen, this will be the Appointments within Episode Screen APE -Inpatient Appointment View 1. Select APE 2. Find your Patient 3. Press Return at Basic Details Confirm Screen 4. This will display all appointments. NOTE the difference between Inpatient & Outpatient Appointments. Inpatient Clinics (IPC) VN2.3 9

13 7. REVISING APPOINTMENT DETAILS <REA> REA allows the revision of the Appointment Details Screen 1. Select REA 2. Find Patient & Select relevant appointment 3. Revise details. Inpatient Clinics (IPC) VN2.3 10

14 8. CANCELS ON THE DAY OR DID NOT ATTEND <CND> <DNA> If a patient cancels their appointment on the day (CND) make a note on the clinic sheet. Tell the patient they will be contacted after the clinic with a new inpatient appointment. If a patient does not attend (DNA) make a note on the clinic sheet. 1. Be aware of the repercussions a cancelled appointment could have on the patient Pre-Admission. 2. The new appointment will be allocated as soon as the AAD (Record Attendance & Disposal) for the clinic has been completed. 3. The new appointment must be made in DFU (DNA Follow Up). Inpatient Clinics (IPC) VN2.3 11

15 9. CANCELLATION OF A FUTURE APPOINTMENT <CAP> 1. Select CAP Cancel Appointment 2. Find your Patient 3. Press return at the Basic Details Screen 4. Select relevant Inpatient Appointment 5. The Appointment Details screen will be displayed. Make note of any important information. 6. Record Reason Code (F9) & Reason Text. Notify Pre-Admissions Office EPI Cancelled Appointment View Status Code CNC P - (Cancelled Patient) Inpatient Clinics (IPC) VN2.3 12

16 10. CANCEL & REBOOKING AN APPOINTMENT <CAB> 1. Select CAB 2. Find your Patient 3. Select relevant Inpatient Appointment to be Cancelled & Rebooked. 4. The Appointment Details screen will be displayed. Make note of any important information. 5. Complete Cancellation Details Screen. 6. Rebook the Inpatient Appointment. BE AWARE of the TCI Date & implication of Inpatient Appointment Date Cancelled & Rebooked View <EPI> Status Code CNC PR (Cancelled Patient Rebooked) Inpatient Clinics (IPC) VN2.3 13

17 11. CANCELLED & REBOOKED VIEW <APE> NOTE: 1. New Inpatient Appointment 2. CNC PR (Cancelled Patient Rebooked) 12. REINSTATE A CANCELLED INPATIENT APPOINTMENT <RCA> 1. Select RCA Reinstate Cancelled Appointment. 2. Return thorough the Basic Details Screen. 3. Select Appointment to be reinstated. The Appointment Details Screen & the Cancellation Details Screen will be displayed. 4. Enter Y to reinstate the selected appointment. NOTE: This function will overbook without warning even if the appointment has been allocated to another patient. Inpatient Clinics (IPC) VN2.3 14

18 13. TOA RECORD PAST APPOINTMENT/ WALK-INS. This function is used to add a patient to a past clinic and may also be used to add patients onto future clinics. Please add a patient to the appointment time that reflects the actual time the appointment took place. WARNING If the patient s Waiting List Activity has not been entered on the system, you MUST add the Waiting List data in the Waiting List function of WLA. WARNING If the patient s Booked Preadmission has not been entered on the system, you MUST add the activity in the Pre Admission function of PAD. TOA does not allow all the relevant data required to be entered. 1. Select TOA. 2. Select Inpatient at Department/Service Group Box. 3. Select Clinic & enter date 4. The Inpatient Select Timeslot Screen will be displayed. Select time slot nearest to the actual time that the patient attended. 5. Select Patient, Return thorough Basic Details Screen. 6. Select correct Pre / WL episode to attach the inpatient appointment to. 7. Complete Take on appointment Screen. This part of the system is under review. Inpatient Clinics (IPC) VN2.3 15

19 14. REPORTS There are many reports available; each department should look at the various formats to decide which report(s) will suit their working practices Inpatient Diary Reports <IDR> Inpatient Diary Reports produces a report for all the patients for the specified Consultant/Clinician for the specified date. 1. Select IDR 2. Reports F9 & select ALD 3. Request Type F9 & select On Demand 4. Command F9 & select Add 5. Complete Screen details Inpatient Clinics (IPC) VN2.3 16

20 14.2. Inpatient Diary Dump <IDD> Inpatient Diary Dump produces a report for all the patients for the specified Consultant/Clinician for the specified date range. 1. Select IDD 2. Request Type F9 & select On Demand 3. Command F9 & select Add 4. Complete Screen details Inpatient Pulling List <IPL> Inpatient Pulling List produces a report for all the patients for the specified Consultant/Clinician for the specified sort & date range. 1. Select IPL 2. F9 To select required sorted by option 3. Request Type F9 & select On Demand 4. Command F9 & select Add 5. Complete Screen details Inpatient Clinics (IPC) VN2.3 17

21 14.4. UCI IP Unrecorded Clinic Attendance Report This report is used to check that all attendances have been completed for the clinic / date specified. 15. RECORD ATTENDANCE & DISPOSAL <AAD> After your clinic has finished, you must record the attendance for patients that have attended an Inpatient clinic. 1. Select AAD 2. Select Inpatients at the Department / Service Group Box. 3. Enter Clinic Title & Date A list of patients on the specified clinic will appear - F9 to select relevant attendance codes. The whole clinic must be complete. NOTE: If your patient cancels on the Day or Did not Attend, the function of DFU must be used to rebook inpatient appointments, see following page. Inpatient Clinics (IPC) VN2.3 18

22 15.1. DNA Follow Up <DFU> 1. Select DFU 2. Select Inpatients at the Department / Service Group Box. 3. Enter Clinic Title & Date 4. A list of CND & DNA patient will appear. 5. Select patient one by one & complete the comment field & F9 to select appropriate action. Either rebook the patient an inpatient appointment or sent a letter to the GP. BEWARE of the implications on the Pre- Admission date! NOTE: As each patient is dealt with the field F/U status is populated with information and any free text comments are displayed. Inpatient Clinics (IPC) VN2.3 19

23 16. INPATIENT CLINIC ENQUIRY FUNCTIONS Clinic Booking Summary <CBK> Clinic Booking Summary displays information for the specified clinic. CBK can be used to view the clinic lag, (how long would a patient have to wait for the next free appointment). NOTE: L will recall the last clinic viewed, if typed at the Clinic field. 1. Select CBK 2. Select Inpatient from the Clinic Booking Summary Screen 3. Enter Clinic Code (F9) / Doctor Code (F9) and Start Date. Your specified clinic details will be displayed. If a minus sign is display, this would indicate appointment types that are overbooked. Inpatient Clinics (IPC) VN2.3 20

24 16.2. Clinic Enquiry <CEQ> Clinic Enquiry gives on the screen details of patients attending your specified clinic. NOTE: Typing L to view the last clinic accessed may be used at the clinic prompt. 1. Select CEQ. 1. Select Inpatient at Department/Service Group Box. 2. Select clinic and enter clinic date. Patients attending the specified clinic will be displayed Cancel Suspend Clinic Enquiry <SCE> Cancel Suspend Clinic Enquiry displays on the screen information for suspended clinics (that you have booking access for) for a specified day. 1. Select SCE 2. Select Inpatient if Department Service Group Box is displayed. 3. Enter Enquiry Date Clinics that you have booking access for will appear on the list if it is relevant. These clinics may be selected to obtain a list of patients that are on the Suspended Clinic. Inpatient Clinics (IPC) VN2.3 21

25 17. SHORT CUT CODES F First Appointment available of the Type specified i.e. PON, POF or PTA T Today s Date T6 Six days in the future T-6 Six days in the past 1W One week in the future 2W Two weeks in the future etc 1M One month in the future 2M Two months in the future etc 14M 14months (the system does not accept 1YR) B Back When entering a date/time for the appointment. NOTE: Will not work once you have progressed to the Appointment Details Screen. V View At appointment slot will display details of Patients that are already booked to the clinic, very useful when allocating an extra patient to a fully booked clinic. Inpatient Clinics (IPC) VN2.3 22

26 18. FAULT REPORTING From time to time you may experience problems with faulty equipment, software problems or access to the Patient Administration System (PAS) ie password non acceptance problems. To resolve your problem a call with need to be logged with the IT Service Desk IT Service Desk IT.servicedesk@iphis.nhs.uk Phone 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 KB 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 Out of office hours Contact the IT Service Desk and leave a message on the answer machine. They will deal with the problem as soon as they can. Alternatively them. If you feel there is a major system problem contact the switchboard for them to contact the engineer on call IT 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 IT Training. it.training@porthosp.nhs.uk Phone Inpatient Clinics (IPC) VN2.3 23

27 19. 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 IT Training Office. * If you have not used PAS for more than 12 months you will be required to re-attend your training. IT.Training@porthosp.nhs.uk Phone Inpatient Clinics (IPC) VN2.3 24

28 20. IT 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 IT 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 IT Training Manager within 3 days of the course/test date. The IT Training Department will keep a record of such discussion together with date and outcome. Where necessary the 1 st marker will be asked to re-mark and the marking checked by the IT Training Manager. 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 ) to the Head of Engagement & Delivery within 10 days of the candidate receiving their result, outlining clearly the circumstance of the appeal. The 1 st & 2 nd markers will meet with the Head of Engagement & Delivery 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 and the Training Manager is unable to resolve the impasse then the candidate may write to the Head of Engagement & Delivery (within 5 days of receiving the 3 rd 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. IT Training QAH April 2015 Inpatient Clinics (IPC) VN2.3 25

29 21. VERSION CONTROL/LOG Manual Inpatient Clinics Version VN2.3 Date April 2015 Revisions Page Updated Formatting headers and footers All Updated IT changed to IT All Updated Telephone Number/ / web address updated Various Manual Inpatient Clinics Version VN2.2 Date August 2011 Revisions Page Updated Formatting headers and footers All Manual Inpatient Clinics Version VN2.1 Date February 2008 Revisions Updated Formatting and text refinements (unlisted as content and meaning unchanged) Page All Inpatient Clinics (IPC) VN2.3 26