Downtime – Ward Attender Form - Adult/Child

Objective:

The purpose of this form is to record patient encounter details during a period of planned or unplanned EPR downtime. The completed form will be used to re-enter details into EPR when it becomes available.

Important: Please complete all fields on this form. The areas highlighted in yellow are mandatory.

AUDIT – MANUAL DATA ENTRY
(Please fill in once details are entered into EPR after downtime)
Name of User: ______
MRN Allocated: ______
Date Entered in EPR: ______/______/______
Time Recorded in EPR: ______
Comments: ______
MRN Number
NHS Number
FIN Number* / Allocated by A&E Reception*
Title
Surname
First Name
Date of Birth
Age
Gender
Ethnic Category (Please tick as appropriate)
Asian – Any Other Asian Background / Mixed – White and Black African
Asian or Asian British – Bangladeshi / Mixed – White and Black Caribbean
Asian or Asian British – Indian / Other – Any Other Ethnic Group
Asian or Asian British – Pakistani / Other – Chinese
Black – Any Other Black Background / Other – Not Known
Black or Black British – African / Other – Not Stated
Black or Black British – Caribbean / White – Any Other White Background
Mixed – Any Other Mixed Background / White – British
Mixed – White and Asian / White – Irish
Legally resident in UK?
(Please tick as appropriate) / No
Unable to Validate
Yes – Confirmed
Yes - Unconfirmed
EHIC Card Present?
(If appropriate) / No
Yes
GP Details(Please include full name and address)
GP Name and Address:
Appointment Type (Please tick as appropriate)
Ward Attender New
Ward Attender Follow Up
Appointment Date:
Appointment Type:
Main Specialty:
Treatment Function:
Appointment Location:
Source of Referral (Only for Ward Attender New) (Please tick as appropriate)
A&E Dept Referral / GP with Special Interest
Allied Health Professional / Indirect ERS Referral
Community Dentist Referral / National Screening Programme
Consultant (Not ED) Referral / Optometrist
Dentist Referral / Orthoptist
Following A&E Attendance / Other - Referrer To Manager Episode
Following Domiciliary Visit / Other Source of Referral
Following Emergency Admit / Prosthetist Referral
GP Referral / Self-Referral
Specialist Nurse (Secondary Care)
Referral Received Date(Only for Ward Attender New):
Service Type Requested (Only for Ward Attender New) (Please tick as appropriate)
Advice/Consultation
Other
Specific Procedure
RTT Status (Only for Ward Attender New) (Please tick as appropriate)
20 Not Yet Treated
20 Request for Diagnostic Assessment
Priority (Only for Ward Attender New) (Please tick as appropriate)
Cancer 2WW
Rapid Access
Routine
Urgent
Address and Patient Contact Details:
Permanent Address:
Post Code:
Home Number:
Mobile Number:
Parent / Guardian(Mandatory for Children)
Relationship to Patient (Please tick as appropriate)
Brother / Parent Unspecified
Carer / Partner
Child / Polygamous
Child/Insured Responsible / Polygamous Partner
Dependent / Proxy - Communication
Father / Proxy - Contact
Foster Parent / Proxy – Contact and Communication
Guardian (other than a parent) / Relative
Mother / Sister
Non-Dependent / Spouse
Not Known / Step Parent
Other Next of Kin

Parent / Guardian Details:

Surname:______

First Name:______

Address:______

Post Code:______

Home Phone Number:______

Work Phone Number: ______

Mobile Phone Number:______

If Patient is a Child, are they Looked After Child: Yes No

Social Worker:______

School Name and Address: ______

______

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