COMPLIANCE WITH THIS DOCUMENT IS MANDATORY

Transcription

1 COVER SHEET NAME OF DOCUMENT TYPE OF DOCUMENT Procedure DOCUMENT NUMBER DATE OF PUBLICATION Published: July 2009 Amended: June 2011 RISK RATING Medium LEVEL OF EVIDENCE N/A REVIEW DATE April 2014 FORMER REFERENCE(S) Former SESIAHS PD 232 EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR Director Nursing and Midwifery Services AUTHOR Health Information Management Committee KEY TERMS DOCS, unborn babies, at risk, prenatal report SUMMARY This document aims to provide guidance about an areawide electronic system within the computerised patient administration systems to flag the mothers of unborn babies identified as being at risk by the Department of Community Services (DoCS). COMPLIANCE WITH THIS DOCUMENT IS MANDATORY Feedback about this document can be sent to

2 1. BACKGROUND This document aims to provide guidance about an area-wide electronic system within the computerised patient administration systems to flag the mothers of unborn babies identified as being at risk by the Department of Community Services (DoCS). The prenatal report and the other factors set out in the new 23(f) Act as extra risk factors that must be taken into account when assessing risk of harm. If the risk factors that gave rise to the report are still present and/or there are reasonable grounds to suspect the child is at risk of harm, reporting to DoCS is mandatory. 2. DEFINITIONS CHIME DoCS ED EDIS eindex EMR HOSPAS HRTOS ID ipm MRN ObstetriX PAS PMI POW SCH SES SESIH UID UPI Community Health Information Management Enterprise Department of Community Services Emergency Department Emergency Department Information System Area Unique Patient Identifier Software Electronic Medical Record Hospital Patient Administration System Health Reform Transitional Organisation - Southern Patient Identifier that identifies the person via a hospital stay (eg: MRN, UID etc) isoft Patient Management software Medical Record Number Obstetrix Information System Patient Administration System Patient Master Index Prince of Wales Sydney Childrens Hospital South Eastern Sydney South Eastern Sydney Illawarra Health Unique Identifier Unique Patient Identifier 3. RESPONSIBILITIES Child Protection Manager CHIME Data Manager EMR Representatives UPI Department Medical Record/Clinical Information Manager Birth Unit Managers / Nursing Managers of Maternity and Delivery Suites 4. PROCEDURE 4.1 Notification is received from DoCS officer to the Child Protection Manager within the HRTOS. The Child Protection Manager will contact the UPI Department to search / Revision 2 Trim No. D09/36214 Date: June 2011 Page 1 of 4

3 register the patient within the ipm / e*index (with the information provided) and identify if the patient has attended the LHN previously. 4.2 If the patient is currently registered with the Facility, a Special Alert Flag is assigned to the patient s ID in ipm. The patient may have presented using an alias if DoCS are aware of any aliases, these will also be recorded. 4.3 The Special Alert Flag within PAS will be a security alert Risk to Others Behavioural Risk, with a comment to state that this is a Birth Alert. For sites to view this alert they will need to bring up the patient in ipm, select patient record enquiry then select alerts to view all administrative related alerts. 4.4 If the patient is not registered with the Facility, the patient will be registered and flagged with a Special Alert Flag. Any information provided by DoCS, such as alias names and multiple addresses etc, should be recorded in PAS. When limited information is provided, follow former SESIH PD101: UPI -Patient Registration, Section : Unknowns. 4.5 In order to ensure that all birthing units and Emergency Departments can add these records into their databases, an MRN is to be allocated within ipm (by the UPI Department) for the following active SES LHN sites: St George POW SCH Royal Women s Sutherland Sydney Bulli District Milton Ulladulla Shoalhaven District Wollongong Shellharbour C213 C208 C238 C220 C214 A233 P202 P205 P207 P208 P The UPI Department will the unborn baby Birth Alert to St Vincent s Medical Records Department (along with a scanned copy of the request from DoCS) so they can add an MRN for this patient in HOSPAS and assign the unborn baby Birth Alert. 4.7 The UPI Department will the unborn baby Birth Alert to all Medical Record Departments (along with a scanned copy of the request from DoCS) to enable flagging of any physical records that may exist. If a physical medical record exists at any LHN site, the Birth Alert form from DoCS must be placed in a sheet protector at the front of the medical record. If there is no physical record at the site, the documentation can be discarded in a confidential manner. 4.8 The UPI Department will the unborn baby Birth Alert to the St Vincent s EDIS Data Manager (along with a scanned copy of the request from DoCS). This will also Revision 2 Trim No. D09/36214 Date: June 2011 Page 2 of 4

4 notify that the MRNs have been assigned so EDIS Data manager can add this patient to EDIS and assign the unborn baby Birth Alert The St Vincent s EDIS Data Manager (or representative) will add the patient to the EDIS External Register within the EDIS PMI with the Birth Alert so that this information will be available to all St Vincent s staff accessing the patient s information in EDIS. If the patient already exists in the EDIS PMI, the baby Alert is added against the existing record. If the patient has never been to that hospital s Emergency Department, the patient is manually added into the EDIS PMI with all demographic details provided by DoCS (from the DoCS form) then an alert is attached. 4.9 The UPI Department will ensure the patient is in the Area CHIME database. If the patient already exists in CHIME, the alert that is added in ipm will be automatically sent and processed and inserted into CHIME for this patient. If the patient does not exist in CHIME the UPI Department will create the patient in CHIME from eindex and then add the alert in ipm, which will be automatically sent and processed and inserted into CHIME for this patient The UPI Department will ObstetriX Data Managers (faxing the DoCS details received) with details of the unborn baby Alert and information that the MRNs have been assigned so the relevant Birthing Unit can add this information to a folder containing Alerts located in that Birthing Unit. Contact details for the Birthing Units are as follows: Hospital Phone Fax Wollongong Hospital Shoalhaven District Memorial Hospital Milton Ulladulla Hospital The Sutherland Hospital The St George Hospital Delivery Suite: Birth Centre: Delivery Suite & Birth Centre share the same fax: Revision 2 Trim No. D09/36214 Date: June 2011 Page 3 of 4

5 4.11 The UPI Department will record an alert against the patient in the electronic medical record. The appropriate alert is Potential risk of physical aggression or neglect - New Born. Similarly, when the alert is to be end dated, the alert should state When the alert is no longer valid, the emr alert should be modified with the status changed to Inactive. In the case of the emr, when any clinician (including the Triage Staff in ED), notice that a patient has an alert icon against their record, they should access the alert tool or alert view in the patients chart to read the alert. Alert icons are viewable in the patient search screen and on patient lists including the Tracking List In the case that any of these flagged patient s presents to one of the HRTOS hospitals via an ED or Birthing Unit or any other location, they will be identified as requiring a DoCS notification. If the risk factors that gave rise to the report are still present and/or there are reasonable grounds to suspect the unborn child is at risk of harm, the treating clinician must make a mandatory report to DoCS as soon as possible by calling DOCUMENTATION If a physical medical record exists at any Facility, the Birth Alert fax from DoCS must be placed within a sheet protector at the front of the medical record. The Child Protection Manager is to maintain a register of all Birth Alerts received, actions taken, dates and times and details of where the Birth Alert was distributed. Birthing Units are to maintain a folder containing Birth Alerts. 6. AUDIT Distribution details to be reviewed in 12 months for deactivation. 7. REFERENCES Children and Young Persons (Care and protection) Act 1998 Miscellaneous Amendments Act 2006 Section 25 Parts a, b and c PD101: UPI Patient Registration (Section : Unknown Patients) 8. REVISION AND APPROVAL HISTORY Date Revision No. Author and Approval July Health Information Management Committee (Andja Rezo) authored and approved document. Approved by Chief Executive at Clinical Council April Andja Rezo as per changes to the Health Reform Transitional Organisation - Southern and additional requirements for clinical systems June As advised by RHW Exec, no more faxing of Birth Alerts will take place to RHW. All notifications will be via the existing process Revision 2 Trim No. D09/36214 Date: June 2011 Page 4 of 4