About the Course The PROTOS record holds general demographic details about a patient and details of any episodes of Maternity care occurring at hospitals within the Portsmouth area. Protos interfaces with the PAS system. When a mother delivers a home birth or when the interface between Protos & PAS is not working, then the details have to be recorded manually. The course will enable students to search for maternity patients, identify specific episodes and document maternity records.
Search for, select and change patient’s details if necessary.
Identify episodes relating to maternity.
Record the details of a home birth.
Delete a maternity record.
Record a hospital confinement.
Link mother to baby or baby to mother.
Unlink mother to baby or baby to mother.
Edit birth details.
Display knowledge of their personal responsibilities for Data Protection and the Caldicott Principles.
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:
I Further information can be accessed through the Trust Intranet:
Information Governance (Departments sections), and
Management Policies (Policies section) nformation Quality Assurance
NHS Codes of Conduct:
The Data Protection Act (1998)
The Freedom of Information Act (2000)
Caldicott Report (1997)
2.1.What can you do to make Information Governance a success?
2.1.1.Keep personal information secure
Ensure confidential information is not unlawfully or inappropriately accessed. Comply with the Trust ICT 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 e-mails, secure postal or fax methods)
2.1.2.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.
2.1.3.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.
2.1.4.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.
2.1.5.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.
2.1.6.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.
2.1.7.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
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:
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: ICT 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.
LOGGING INTO ADT
Log on to PAS in the normal way.
At the Patient Master Index Menu, press the Function Key F6. This will show all the function sets you have access to.
FUNCTION KHO KORNER HOME CONFINEMENTS
Korner Maternity Details for Home Confinements are recorded manually onto PAS by the Maternity Reception staff.
The Korner Home Confinement is recorded against all planned / unplanned Home Confinements.
Planned Home Confinement = Booked to deliver at Domestic Address.
Unplanned Home Confinement = Booked to deliver in the Maternity Unit but delivers at Domestic Address before reaching unit.
Home Confinements will be recorded by the Midwives on the PROTOS System using the following protocols:
Method of Delivery
This would normally interface with PAS at 3rd stage to register the baby automatically, generating an NHS number and B birth registration number.
Main Reception will enter the KHO onto PAS using the Pre-discharge Assessment forms
(aka Korner Maternity Compulsory Data forms) provided by PROTOS.
5.Recording A HOME BIRTH
Using the recommended search in LIS, find the patient and see if there is a referral for maternity care; this can also be viewed in EPI, episode enquiry.
Select KHO and start to record the details
DON’T FORGET YOU CAN USE THE HELP KEYS: F8 AND F9.
Parity Enter the number of previous register births or U if unknown.
Pregnancy Enter pregnancy number 9 = 9 or more previous births; U for unknown.
Number of babies Babies born.
Date of 1st ANA Enter date of 1st antenatal assessment. N if not applicable, U if unknown.
GP Code Press return if patient’s registered GP (F9 and select non-register GP if appropriate).
Gestation Enter the number of weeks pregnant – 99 represents unknown.
Birth order Is 1 unless you are recording twins/triplets etc in which case each baby’s birth details will need to be recorded separately.
Birth weight Enter in grams or U for unknown
Live/still birth Please be guided by the policy regarding this.
Comments Add if necessary.
MOR – Positive pressure, (Method of resuscitation) Mandatory field, use F9 superhelp.
MOR – Drugs: Mandatory, use F9
NB: If you have said yes to drugs then type in the drugs used, this is a free text field.
Delivery Date: – Mandatory, type in the date or you can use T for today’s date.
Time: - Put in the time of delivery.
Method of Deliver: – use F9 super help.
Presentation of fetus: Press F9 and select.
Sex of Baby F9 and select or type in the appropriate code.
Smoking Mandatory - F9 and select.
Enter Y for yes or N for no.
This episode is visual in KHO, where you may also list or revise the data recorded.
In EPI, episode enquiry, you will see the home conf but you cannot select it.
6. Linking the baby via the mother
Check, has the baby been recorded onto PAS? Use PMI Add/Revise function to record the baby’s
details if the baby is not on PAS.
Note: The mother is the dominant patient and searched for first within PAS.
Select LIS – Using the recommended search procedure, search for the Mother that you want to link to their baby. Check the patient’s demographics to ensure that you have the correct patient.
Select LPM – Link Baby via Mother
3. To recall the Mother’s PAS record use the L for ‘last’ command, in one of the first five fields.
4. Enter Y (for Yes) if you have the correct patient.
5. Search and select the baby that you wish to link to its Mother.
6. To link the mother and Baby – At the Are Theses Patients Linked? Enter Yes
And then at enter - yes
The Link to the Baby via the Mother is complete.
Please note: that you can also link mother via baby using the function of LPB
7.Linking the mother via the baby
Note: The baby is the dominant patient and searched for first within PAS.
Select LIS – Using the recommended search procedure, search for the Baby that you want to link to their Mother. Check the patient’s demographics to ensure that you have the correct patient.
Select LPB – Link Mother via Baby
3. Using the recommended search procedure search for the Baby which you which to link to their Mother.
4. Select the correct baby form the Patients offered.
5. You will be asked to confirm that you have the correct patient.
6. Search for and select the baby’s Mother.
7. You will be asked ‘Do you wish to revise the following?’. Are the patient’s demographics correct or do that need updating? Update if necessary.
8. Both the Baby and the Mother’s names will be displayed for you to confirm that these are the patients to be linked. Enter Y for Yes at the prompt to complete the linking of the patients.
8.Recording a hospital confinement
If the interface from Protos to PAS is not working or the network connection to PAS is lost, hospital confinements are added manual onto the system using the PAS function of KMO.
1. Select KMD – Korner Maternity Details
2. Select the IP ADM (Inpatient Admission) to record the stats against.
The fields are the same as KHO but your selection from the F9 lists will be different.
The example shows an episode of Caesarean section where it wasn’t the original intention. The 2nd stage is 00.00 time as the decision to operate excluded the second stage; this isn’t always the case.
Complete the rest of the fields and at enter, type Yes.
9. Deleting Korner Maternity
If you have made an error you are able to delete the data entered using KDD ‘Korner maternity Delete’. Caution must be taken that you are deleting the correct activity.
1. Select KOD
2. Select the Home CONF episode. You will be asked it the information displayed is the activity that you wish to delete.
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 ICT Service Desk.
10.1.ICT Service Desk
Phone 023 9268 2680 or SJH (7703) 2680.
You will need to give the Service Desk certain information, so always ensure you have the following information available. They may need to know:
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.
10.2.Out of office hours
Contact the ICT Service Desk and leave a message on the answer machine. They will deal with the problem as soon as they can. Alternatively email them.
If you feel there is a major system problem contact the switchboard for them to contact the engineer on call.
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 ICT Training.
If you have only just attended the course and feel you may need additional support, help or advice, you can contact the ICT Training Office.
* If you have not used PAS for more than 12 months you will be required to re-attend your training.
Candidates who are unhappy with any aspect of the end of course/test assessment decision should first discuss the problem with the ICT 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 ICT Training Team Leader within 3 days of the course/test date.
The ICT Training Department will keep a record of such discussion together with date and outcome.
Where necessary the 1st marker will be asked to re-mark and the marking checked by the ICT Training Team Leader.
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 e-mail) to the ICT Training Manager within 10 days of the candidate receiving their result, outlining clearly the circumstance of the appeal.
The 1st & 2nd markers will meet with the Training Manager 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 then the candidate may write to the ICT Training Manager (within 5 days of receiving the 3rd 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.