Public Health & Intelligence

/ Gyle Square
1 South Gyle Crescent
Edinburgh EH12 9EB
Telephone 0131 275 6000
NHS Board Unscheduled Care Leads
cc Information Leads / Date 12 November 2015
Your Ref
Our Ref
Enquiries to
Direct Line 0131 275 2092
Direct Fax
Email

Dear Colleague,

Recording specific A&E data items

There continues to be variation in the application of recording rules between NHS Boards and I am writing to you to reinforce the current recording guidance around ‘Referral Source’ and ‘Date and Time of Discharge’ data items for the A&E dataset.

Referral Source

Revised guidance was issued in 2011 for the recording of the data item ‘Referral Source’. Some Boards continue to record ‘self referral’ incorrectly for patients who arrive by ambulance.

Patients who are brought to A&E by the ambulance service should not be recorded as a ‘Self referral’ For example, if a patient or bystander calls an ambulance, the ambulance crew will assess the patient and make the clinical decision whether the patient needs to be taken to A&E. In this situation, the ‘Referral Source’ should be recorded as ‘02C 999 emergency services’. If a GP sees a patient and then calls an ambulance to take a patient to hospital, it would be the GP that is recorded as the ‘Referral Source’.

Date and time of discharge

The ‘Date and Time of discharge’ is used to calculate the length of time that patients spend in the A&E department and measure compliance with the 4-hour emergency care standard. Several NHS Boards have recently requested guidance on the recording of patients waiting for transport.

Patients who have been discharged from any further care in A&E, may sit in the departments reception area waiting on transport (either private or Scottish Ambulance Service). These patients are no longer ‘on the clock’ and the time of discharge is the time the A&E care ended.

However, if it is not safe for the patient to be discharged from A&E care whilst waiting on transport (private or Scottish Ambulance Service) then they remain ‘on the clock’ until they leave the department.

The full A&E data manual and recording guidance is available here.


Please do not hesitate to contact the team here at ISD should you require assistance with the definitions or mapping of local to national codes either via telephone on 0131 275 2092 or email or .

Yours sincerely,

Fiona MacKenzie

Service Manager

ISD

HFS1114 V10