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SBR Clinical User Manual - Information Services Division

1. A blank screening form with only the patient information pre populated e Pre populated Newborn Hearing Screening form This form is pre populated with GP and Mother details taken direct from Mother tab SBR Clinical Manual Version 6 8 February 2014 Page 36 Section 15 Delete Record There are a number of reasons why you may want to delete a record from the SBR including error miscarriage termination intra uterine death and moving out with area If you need a record deleted you should contact your local SBR administrator to do this for you You should also contact the SBR Team if you identify that there is a duplicate record for either the mother or the baby or if you accidentally delete a record and you wish it to be retrieved Note that the deleted record will remain on the main database with a note of who has deleted the record and why To contact an administrator click on X beside the appropriate record to bring up a list of administrators contact details or please refer to section 10 Contact for the SBR team SBR Clinical Manual Version 6 8 February 2014 Page 37 Section 16 Duplicate Records It is important that every baby has only ONE record This avoids having spilt records i e a mother s record with no baby details or a baby record with no mother details To avoid duplicate records it is important you search for an existing record before adding a new one especially if they have been transferred from another hospital
2. E Amin jp e Click on from the main dashboard e Search using Baby Mother CHI number or SBR Indicator e Click on Search you will be presented with the screen below detailing more record information linked to your search and most importantly the site the record is located at Enter CMI or SBR Indicator Baby CHI SSR Ind Mother CHI lt Cem Name Psp CMI Doll 17 COM Hunt Ree DOA mo we deem Oe Creed SBR Clinical Manual Version 6 8 February 2014 Page 6 Section 5 Creating a New Record Before adding a new record it is advisable to search the database to ensure a record does not already exist see Section 4 Finding your Patient Record There are two options for adding a new record either by entering the Mother s details with the ability to add Baby s details when required by using Add New or entering only baby s details if appropriate via Add new neonatal record to create a new baby record without the mother information To add a new record for the Mother e Click on Add New from the main dashboard e This opens a screen Mother Details Stage 1 Complete all the mandatory fields marked with these are Surname First Forename and Date of Birth If possible also complete mothers CHI number and Hospital Patient Identifier HPI e Click on Next you will be presented with a screen listing possible matches for the mother Mother is not listed Screen Mo
3. If you create find a duplicate record it is important that all the data is merged into one record by transferring all relevant information on to the appropriate record and deleting the duplicate You need to contact a local site Administrator to delete the record you do not require Please remember when merging a record you will need to take into account if there are any episodes transfers or if the record has been sent from another site If one of the records has a CHI number for the baby this record must be used to avoid a duplicate CHI being created The Universal Newborn Hearing Screening UNHS UNHS System also uses the SBH record when a duplicate appears in SBH it will also appear in UNHS You may need to contact a hearing screening colleague to ensure the correct record is being deleted You should not delete a record without checking with hearing screeners as it may contain hearing screening test results and other important data The SBR UNHS helpdesk can provide a list of contacts To find duplicated records within your site please go to Admin tab Duplicate Record section and click on Within site link See below gt gt Las ott m This report will open in an excel spreadsheet It is important to do a through search both locally and nationally before you create a new record in case there is already an existing record Section 17 Audit Trail There is an activity log incorporated into the system at data item and username l
4. Contact Finding A Record Locally At Your Hospital The search facility can be found on the top of the dashboard Surname Forename alt HFI DoB EDD SBR Ind ML LM CL pe E Mum Baby Both EDD Baby DOB Mumnog C e Search for mother baby or both using partial surname forename HPI alternative HPI Community Health Index CHI number Expected Date of Delivery EDD Baby DOB Mum DOB or SBR Indicator e he SBR Indicator is a unique system identifier for each SBR record It can be found below the surname on the dashboard Doby Surname Forename Baby mum Gaby DOB OF bern Mospita Patera ID CH 5 Pecorts m tela Pape 1 of 2 Green Baby 14 08 2008 not entered EN Gp Orange Baby 14 08 2008 not entered AE p IE Qu e Enter the data you are searching on i e surname DOB CHI e Click on the Search All button e Results will also include any alternative previous surnames e Remember to select mum baby or both it is recommended that you select both e There are two boxes in the section for searching on EDD Baby DOB or Mum DOB If you want to search just on a singular date you can enter this in either box If you want to search on a range of dates put the start date in the left box and the end date in the right hand side box e f you want to search for certain groups of records i e those with EDD dates you need to change to a dashboard view that shows them i e All or Booked but no
5. The SBR system will automatically log you out of the system if it has not been used for 20 minutes However any unsaved data will be lost SBR Clinical Manual Version 6 8 February 2014 Page 30 Section 12 Send Function send The function can be accessed from the dashboard and allows users to move the record to another site without adding an episode for the baby This could be used if the record was created at one site but the mum moved or gave birth at another site The send function changes access for the record to the users at the receiving site and should only be used if the mother baby is not currently admitted at your hospital Note that once you have sent a record you will no longer be able to access it so please ensure that you complete the record as much as possible before sending it to another site At your location on the dashboard screen you will see the record details however they are greyed out It will detail where the record was sent to when and the username of who sent the record This record will no longer be accessible until it is either transferred or sent back to your site If a baby is admitted to your hospital and then moved to a different hospital in Scotland then this is classed as a transfer and you should use the transfer screen refer to the Episode Screen section for further information The in utero transfer function should only be used when mum is admitted or reviewed and transferred to another hospital
6. e Monthly Report cover the previous six months and they display the following Birth Number Outcome Place of Birth Birthweight Gestation Feed on Discharge Parity Onset of Labour Induction Augmentation General Anaesthetic Epidural Anaesthetic Local Anaesthetic Spinal Anaesthetic Blood Loss Placenta Delivery Tears Episiotomy Type of Delivery e Coding Status Report This report will show all the records that have not been submitted to ISD i e they have not been coded or are only partly coded e Coding Status Chart This will display a chart of coded partially coded and yet to be coded records by month for a specified year SBR Clinical Manual Version 6 8 February 2014 Page 26 Section 9 Export Data Clicking on tees Dal from the main dashboard allows information to be taken from the SBR and printed out or analysed locally Exporting Data This will allow you to download your data to your local computer These data contain patient identifiers such as names and addresses as well as confidential information Once downloaded they become your responsibility They must therefore be treated with care in accordance with data protection legislation In particular they should be stored appropriately according to local guidelines for the storage of such data on computers On selecting your download you will be given the choice of saving it locally or opening it directhy on your PC See useful Tips for displaying data Clini
7. A 25 SBR User Manuals and Quick Guides cccccccccccccccccccccccnonnnnnnnnnnnnnnnnnnonnnnononononnnnnnnnnnnnnnnnnnnnnnnnnnnonanannns 25 Automated IMportS EM 25 Record Movement EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEMMMM 25 DSECHOM GO gt REPONS serian eninin E sacs iiaa aaa Enin nara Dadia anai SAAR 26 Seon O ENON Dala TED 27 SalI STIGS MOM INe OBH NN E m EERE AEAEE nE REE 28 vr elo MN TO Qo 6 ERN E en E leidas 29 It is important that you do not use any confidential data in emails cococcccccnnncconnnoconnnnnnnnnnnnnnos 29 SC OEE Heer 8 ASP 30 CGO T end FU IO errata ano air aca 31 elo o ERR 32 CHI Date of Birth and Sex field validation oocoocoocooccoccnccnccnconcnnnoncnononnnoncnnnnnnonnnnrnnnonnnnnennnnnnnnnnns 33 KOED EXISUNO CHI DURON e 34 Allocate New CHF DUTON accord erica 34 When NOT to Allocate a CHI on the SBR caeteris eve aad Und ark na eruat ee 35 Error Messages when obtaining a CHI Number ccccccecccseeeeeeecaeeeeceeecaaeeceeeseaaeeeeessaaeeeeeessaaeeeees 35 Seclion E ad PIER OOM NETS TUE S TRETEN 36 SECON 5 Delete Recon A Mae io tea te de dat EVO du diu ace EU dee Da OE 37 Seccion Te Duplicate Record ime cen 38 A A Te PE EUN 38 SSCHOM IS Raul a aide ie leno has unu i fuU Md pDEE IE 39 EMP Voul bDrowser s telrp MOS cian delicia ibi 39 Section 19 Frequently Asked Questions o
8. C nd Dose Surfactant Date use today s Date Time yg PY 3 Yes Ho Sent home on Oxygen C Yes C Ho How many additional desse Date of Final Oxygen use today s Date Other Ventilation Pneumatharax requiring drainage Wentilated Heedled IFF no of days Chest drain HF OV na of days Nitric Oxide CPAP no of days EChi Postnatal systemic steroids for CLE Maximum base excess Update Close Post Delivery Tab This screen is for the addition of Postnatal Mother details only Please note that all of the data items on this screen appear in the Immediate Discharge Letter Pleate note that ad felde on vs screen relate to mhe Mum and not the Baby rearme S UT f e res E ad s zl Discharge i d wee net e one OS NEL 0 ot et i Juro 7ec09 147 939 ote at SBR Clinical Manual Version 6 8 February 2014 Page 23 VLBW Tab The Very Low Birth Weight VLBW screen is where information on Clinical Risk Index for Babies CRIB and Morbidity data are recorded This tab will only be visible if the baby meets the VLBW criteria birth weight of the baby is less than 1500 grams or the baby is less than 32 weeks gestation Completion of this screen is not mandatory for the Information Services return Using the SBR in the Community Community Midwives can also access the SBR system In some areas this is only to record information on homebirths Other areas per
9. Town village Region County Postcode EH12 HEB Clear Close Search Results 13 3 South Gyle Crescent Edinburgh Midlothian EH12 SEB 157 South Gyle Crescent Edinburgh Midlothian EH1 2 9EB 15 8 south Gyle Crescent Edinburgh Midlothian EHT12 9EB 17 South Gyle Crescent Edinburgh Midlothian EH12 3EB 174 South Gyle Crescent Edinburgh Midlothian EHT12 9EB elect SBR Clinical Manual Version 6 8 February 2014 Page 45 Appendix D Contact The SBR helpdesk is maintained by Atos Origin and is available 24 7 You can contact them in a number of ways Feedback lt e Use the link on the dashboard and complete the form e Email itservicedesk nhss ns atosorigin com e Telephone 0845 957 2700 Atos Origin is the first point of contact if you require assistance They can help immediately with the following Find an SBR User Reset passwords Provide details of who you should contact to get a record transferred Add new postcodes to the system Unlock the baby CHI Any other problems or queries will be passed to the SBR team who will get in touch with you during normal office hours It is important that you do not use any confidential data in emails The SBR Identifier should be used to identify records that are being queried see Section 4 Finding Your Patient Record SBR Clinical Manual Version 6 8 February 2014 Page 46 Appendix E Glossary Discharge when a baby is discharged from inp
10. it will appear in blue and underlined Once the document is open go to File Select Page set up and ensure the header and footer boxes are blank Click on OK a a E To print the document 1 Goto File 2 Select Print The following reports can be generated from The Print Room General Practitioner Reports GPR Report An application form to register with a GP New Born Record A printable version of the data relevant to a new born split into antenatal birth history physical baby examination and medical baby examination e Immediate Discharge Letter A pre populated discharge letter for mother and baby Note if a mother has had no previous pregnancies then it will display on this letter as being para 0 0 Neonatal Discharge Letter A pre populated discharge letter for babies who were admitted for further neonatal care Handover to Heath Visitor Letter A pre populated letter containing information for the Health Visitor Coding Output A pre populated report containing a summary of all the coded data together with the OPCS4 and ICD10 codes for the baby e Blank Coding Output A blank report for recording the coded data items including OPCS4 and ICD10 codes for the baby where the notes are housed elsewhere e Registration of Birth A pre populated Registration of Birth form Notification of Birth A pre populated Notification of Birth form Newborn Hearing Screening Form
11. From CHI 2903115095 Keep Existing CHI Allocate New CHI Forename Baby li Baby surname Pas Pea Date of Birth 2903 2011 29 03 2011 sex Male Male Address 123 HERB POTS 123 H BALCONY VIEVY BALCONY VIEVY EDINBURGH EDINBURGH Post Code EH12 OER Cancel 4 SS d nn nni ni lec Ms 1 Keep Existing CHI button e Click on this button if the details are for the same patient and you are not trying to re allocate the CHI number You will then retrieve the CHI number previously allocated to that baby Allocate New CHI button e f after checking the details you are confident that the details that already exist on CHI belong to a different baby then you can go ahead and get a CHI number by clicking on this button This option would be used for a multiple birth e lf you are reallocating a CHI number to a baby and this message is displayed click on the Allocate New CHI button to get a new CHI number This option would be used where the wrong details had been entered e g wrong sex the first time that the CHI was allocated SBR Clinical Manual Version 6 8 February 2014 Page 34 Cancel button If however you are unsure you think this baby may already be registered on CHI or you want to go back into the record to check it then please click on the Cancel button It is very important that the same baby is not allocated two CHI numbers unless the CHI number needs to be re allocated because it was
12. Ill etc as the CHI interface will not accept numeric characters see Figure 4 SBR Clinical Manual Version 6 8 February 2014 Page 33 E http Eest scattishbirthrecord scot nhs uk CHI Microsoft Internet Explorer provided by BT Yahoo Broadbe nd CHI Registration Please check that the details below are correct prior to registering this baby on CHI Surname Egg Forename Baby 1 Murmerical characters are not valid in this field See information point on baby screen sex Female Date af Bith 06 08 2009 Address THE HOUSE Postcode EH12 9EB Sorry but you do not have enough details for this patient to continue with the CHI registration process Back to Baby Screen E KE Sessonwitmeoutim 08 45 meme Z When the data you are sending to the CHI system closely matches an existing record as will happen in the case of multiple births it will be flagged up as a possible duplicate see Figure 29 and will offer you the following options POSSIBLE DUPLICATE FOUND Baby ii Pea If vau AGREE thatthe details retrieved from CHI are far the same patient please select KEEP EXISTING CHP to import the existing CHI number inta the SBR record e Ifvau are sure thatthis is a new registration please select ALLOCATE NEW CHP to proceed with a new CHI registration This would also apply to a record far a TAIN ar if vau need ta re allacate a CHI number Ifyou are NOT SURE howto proceed please select CANCEL and ask for help From SBR
13. Live System To access the live SBR you will require a unique username and password You can obtain this from your local SBR Administrator or the SBR Team see Appendix D Contact Username vom Mew Password Cunha Hew Passwurd Cancel For first time users or if your password has been reset the password is password Once you have entered your login details you will be prompted to provide your own secure personal password that must be at least 6 characters long with 1 number PLEASE NOTE you must only enter the system using your own unique username and password If you have any problems accessing the SBR including forgetting your password please contact your local SBR Administrator or the SBR team via the Atos helpdesk SBR Clinical Manual Version 6 8 February 2014 Page 2 Section 3 The Dashboard Once logged in you will be presented with the dashboard a screen showing summary patient details that also gives you access to system administration and enhanced system functionality The top section identifies the user site and relevant NHS Board It also provides access to additional functions e Add new record i e Accessing alternative dashboard displays Alerts User alerts where records e Searching for records locally amp nationally require attention e System and password administration e SBR update log is a link to SBR website e Reports providing information about version e Exporting Data changesThese fu
14. can be used within the discharge letters and other documents e When creating a new record those fields which are accompanied by AECA an asterisk are mandatory and must be completed before the new AN Forename cannot be bear record can be added to the SBR If a mandatory field is missing a warning box will appear providing details of the missing data item s which is needed to be completed before the record can be submitted e To find a GP and or GP Practice please use the find button located to the left of the GP Practice Code field see GP and Practice Finder below for further details e tis advisable to use the find button when entering addresses as this automatically populates the fields in a standard format When entering a postcode you must include a space e g FK104QB should be recorded as FK10 4QB see Postcode and Address Finder below for more details e Ifthe connection is slow please do not continually click on the Add Record button when creating a new record as this will create multiple records GP Practice Finder If you know the GP Practice Code and the GP s GMC number you can type these into the relevant data fields The built in search allows you to find any GP in Scotland and any GP Practice throughout the UK The more specific your search the quicker it will run To use the built in search Find l Click on to the left of the GP Practice Code field e e Search on either the GP s surname and or
15. e As well as the CHI the following fields will also be locked once the CHI has been allocated Baby Tab Date of Birth Sex and CHI Birth Tab Date of Birth Sex Routine Examination Date of Birth If a mistake has been made in entering the sex or date of birth the CHI can be unlocked by either the Atos helpdesk or local administrator this should then unlock the Sex field and the Date of Birth field to enable the user to change them accordingly and subsequently allocate a new CHI As soon as a new CHI has been allocated these fields will be locked again These 3 fields are locked only when a CHI number is allocated using the CHI button i e via the CHI allocation web service not when the number is manually entered CHI Date of Birth and Sex field validation If the CHI is invalid due to the Date of Birth or Sex field validation has been put in place in order that the user cannot update the record until the CHI field is a valid number NB Any invalid CHI numbers on your SBR appear in a list on the Alerts page These can be amended by clicking on Alerts on the top right hand corner of your screen If the CHI is unlocked and another CHI allocated please ensure that the Child Health department are made aware of the CHI change so they can stop using the old one It is important that when you are registering multiple births where the baby has no forename and the default Baby is being used that you use Baby Baby ll Baby
16. from your hospital can be viewed on the Admin page under Record Movement In Utero Transfers In utero transfer to another location Date Use today Hospital Transter by e In Utero HB Please note that ance this record has been transferred you will no langer have access to it A list of transferred records can be downloaded on the Admin screen This facility is used when a clinical decision has been made that a mother should immediately be transferred to another hospital for any reason For example if a mother is attending a small community hospital and complications occur during labour a decision may be made to transfer her to a city hospital with more facilities To transfer in utero follow the instructions detailed above for transferring a record however also ensure that In Utero box is ticked Tips for Transferring In Utero See Tips for Transferring above As many women do not know if they will deliver at the hospital they have booked for it is advisable only to forward a record when the destination is certain Readmissions When a baby has been readmitted to hospital after transfer or discharge this must be entered on the episode screen To do this follow the instructions previously detailing how to add an episode If a baby is readmitted to a different hospital following discharge from your hospital the record should be SENT and not TRANSFERRED to the admitting hospital to allow the admission details t
17. the Use Today link below the date field e Select the Type of discharge e Specify where they are discharged to in the free text box e Click on to save the discharge The discharge will be added to the top of the episode history box To remove an episode If you have incorrectly entered an episode of care you can remove it by clicking on the remove link beside the relevant episode Please note that you can only remove the top episode from the episode history therefore if you wish to remove an episode further down the list you must take a note of all the episodes above it and remove them then once you have removed the relevant episode you are required to enter the other episodes back into the system SBR Clinical Manual Version 6 8 February 2014 Page 17 Note You always read the episode history box from the bottom upwards as new episodes of care are added to the top of the list Transferring a Patient a E http test scottishbirthrecord scot nhs uk Episode Transfer Microsoft Internet Ex alore Transfer this baby to another location Date Use today Hospital Transfer by Po HB Please note that once this record has been transferred you will na longer have access to it A list of transferred records can be downloaded on the Admin screen epe tnt Z This screen is used when either the baby or the expectant mother is being transferred from your hospital to another Scottish hospital fo
18. the Practice address e Click on Search e Highlight click on the relevant entry from the list presented of possible GPs and Practices e Click select e The GP Practice Code and GP s GMC number are now automatically completed SBR Clinical Manual Version 6 8 February 2014 Page 43 Hints amp Tips for Searching e For surnames beginning with O just search using O and include some other GP or Practice detail such as forename or partial practice address e For patients in the Armed Forces who are not registered with a GP in the UK please use GP practice Code 99976 e When searching on the practice address enter details in the first line only see below e f you do not find the GP practice you are looking for you can widen the search by removing the address or the GP forename Be careful if you are looking for a common name such as Dr Smith it is advisable to put in the first initial to avoid a large set of results being returned TES Practice feeder Web Page UM GP Practice Finder eri search on all GP Practices in the UK but will only return GMC Numbers for GPs practising GP Sumerne fone GP Foreneene Address lire then final d te search os address detana Postcode EH Seech Clear Cose Search Results 71516 3303995 Jones Co n 24 Gracemount Dive Edinburgh EHIS BAN 0131 64 7513 3205499 Jonas Neil North Berwick Healf Cantra St Bakired s Hond Nom Berwick EH nas V 01620 yde 163 77035 474639
19. 1 Jones Valene Ess eid Medical Practice Eastteld Farm Rood Penicul EHet RET 0 358 755 78109 2983390 Jones len Feuldhouse Health Centre Blsckfeulds Plar 2 Fauldhouse LER 01501 7 70282 70255 4612067 Jones Lucy Howden Haalh Centre Howdan Rood West Livingston West Lofvan EHE ETF 0151 16 423800 Selec Postcode amp Address Finder It is recommended that you use the built in search facility to enter the address and postcode Find e Click on to the left of the address field e Search on either the postcode or part of the address e Click on Sesa e Highlight click on the relevant address from the list presented e Click select e he address and postcode are now automatically completed a amp Tips for Searching The more specific your search is the quicker it will run For example if you are searching for a common street name such as High Street you should also include the town village e Do not enter a house name or number in the address search e When searching on a postcode you must include a space in the postcode e g EH3 9AW instead of EH39AW If an invalid postcode is manually entered a warning will appear on screen Where possible try to find the correct postcode However if you know the address and postcode you can type them in to the relevant fields SBR Clinical Manual Version 6 8 February 2014 Page 44 E Address Finder Web Page Dialog Address Finder street NB Do not use numbers in the Street name
20. 11 AIN PR T E 12 Past Obstetric PISTON NR TE 12 Smoking alcohol and AUGS seeeccceccseeseceeecaeeeeeeecaeeeeeeeeeeeeeeeeesseeeseeeeesseeeeeeeeseeeeeeeeesaeeeeeesssegeeeeesaas 13 IO r i E 14 Ma Examination TID resies ipod 15 size mio Pa 16 Recording Stillbirths and Neonatal death oooocccccncccconconnncnnnnnonononanncnnnnnnnononannnnnnnnnnnnnnnannnnnnnnnnss 16 zecosM 17 Transferring uale REM 18 III 19 FAS AG MNS SHOES ee MPO E 19 Place of Birth Home Births Born Before Arrival amp Born Outwith Scotland 19 LISSA SC UCTS e Y 19 NUM 20 Routine Examination TaD 21 971 3 22 Respratoly o B TIE TT 23 POSTON CI MAD e 23 VEB Ta 24 Using the SBR in the COMMUDNILY cccccseesecccceeesseeeeceeeeceeeceeeueceeecaeaseceeesseaaecesessaaeeeeeessaeeeeessaaeeeess 24 Section 7 System and Password Administration oocccccccoconcnnnccnnnnconnnononncnnnnononncnnnnonnnnrnnononannnnnnnnnnaness 25 LS EF PCM
21. 14 Page 25 Section 8 Reports Clicking on percibe from the main dashboard allows access to reports and graphical analyses of the data entered into the system Reports Lodge Statue The following reports are available e GRO Child Health Report This report gives a list of all the babies born within the hospital can include still births if requested for a specified period of time N B The initial outcome field must be set for baby to appear in this report e SIRS Report A more detailed list of all the babies born within the hospital for a specified time period e Birth List Lists Mum and Baby demographics GP details birthplace and outcome e Episode Activity Management This is a report required primarily for finance The user can choose to limit this report by specifying a date range for the following dates o Date of birth o Date of admission o Internal transfer date o Date of discharge o External transfer date e Patient List reports on patients by either dates of birth gestation birth weight ICD or OPCS codes e Annual Report shows full birth details including gestation birthweight feed on discharge discharge type multiples top 10 diagnoses 4 digits top 10 diagnosis 3 digits ITU days ITU ALOS HDU days HDU ALOS SCBU days SCBU ALOS Vent days VENT ALOS HFO days HFO ALOS CPAP days CPAP ALOS as a number and percentage of total by selected year ALOS average length of stay
22. D10 codes assigned to each SBR for the current hospital OPCS4 Coding Data A record of all the OPCS4 codes assigned to each SBR for the current hospital Episode History Data A list of all episode events for the current hospital SBR Clinical Manual Version 6 8 February 2014 Page 27 Alongside each data extract is a Data Definitions document detailing the content of each extract In addition there is a section on Useful Tips for displaying data that may be helpful to you In order to view these definition documents you will need to have Adobe Acrobat Reader on your computer If you experience any problems opening up these Reports please try the following e Open up Windows Explorer Go to Tools Select Folder Options Select File Types Scroll down to CSV and Click on the Change button and change it so that the association is with Excel You should now be able to open up the SBR file and either save it as an Excel or CSV file If not please contact the SBR Team Statistics from the SBR As the data entered into the SBH is up to date this will give you more accurate timely analysis of different types of data Each Scottish Birth Record has its own unique number which is generated by the SBR system This is called the SBR Indicator You should use this field to link data with and to eliminate any duplicate episodes If there is any specific analyses you require or you just need help getting the data out of the Excel sprea
23. ICU2 NCPAP for any part of the day and not fulfilling criteria for intensive care 1000g and not fulfilling criteria for intensive care Receiving TPN Convulsions Oxygen lt 1500g Neonatal Abstinence Syndrome UAC UVC IA chest drain tracheotomy partial exchange transfusion Severe apnoeas Needing 2 1 nursing care Transported by a trained nurse alone Special Care In the SBR this relates to babies who are receiving any special care regardless of which ward they are in Normal Care In the SBR this relates to babies who are receiving normal care usually on the post natal ward with Mum SBR Clinical Manual Version 6 8 February 2014 Page 47
24. M 5o iud oae ghee be oa ome Bre ds ode Pa Gee etm Er hij j2ufgi a AA T amne tan ord paramo eut ams ca ats Lata tum ov tht bateneg Be stage habas ata ims Hostesi 2 b a9 LO C1 et ngos qpngtyo PUNO ttm m tem Cut e 0 um A lb eee king Baha MV es of dm Tl ae of Con De oe ov Ban pe ta sw ema rd omger m aad cule da AD eee ve tom Cu d D Once data items have been entered into either the Initial Exam or Routine Exam screens a brief summary of this will appear in the boxes on the right hand side of the care screen You can enter these sections by clicking on the add update buttons at the bottom of the individual box or by using the separate tabs across the top By clicking on the printer icon at the bottom of the page you will be able to print off the Neonatal Immediate Discharge letter The respiratory screen can be accessed from the care screen to record any information about intubation oxygen therapy surfactant ventilation and any other relevant respiratory information The screen is accessed by clicking on the button at the bottom of the care page SBR Clinical Manual Version 6 8 February 2014 Page 22 Respiratory Screen ELA Web Page Dialog Respiratory Intubated e uze todays Date A Use Now Surfactant Oxygen Therapy dst Dose Surfactant Date letal deba lime Oxygen therapy at 28 days of age O Yes C Ho f Oxygen therapy at 36 wks corrected age C
25. NHS ee National Services Scotland The Scottish Birth Record Clinical User Manual Version 6 8 February 2014 Table of Contents Section 1 Background amp Introduction ooooncccnnncccccccoonnnnnnnnononononnnnnnnnnononnnnnnnnnnnnnonnnnnnnnnnnnnnnnnnnanennnnnnnns 1 wee a Doo Ely M eee 2 LE eee cM RT 2 MVS MEI TES ILU DTERMC 2 oecon y The DASMOO ANG ERROR EE 3 Viewing Alternative Dashboard Displays ccoooncccncccccnnconccononnconnnonnnnonnnnnnnnncnnnnononnnnnnnnnnnnrnnnnnnnnnennnnnnnas 4 Section 4 Finding Your Patient Record cccccccccssseeceecceeeeeceeesaeeseceeesaeaeeeeesseaseeeeeseaaeeceessaaaeeeeesssanseeess 5 Finding A Record Locally At Your HosSpital o cccococcnnccoconcnccconcnnoconcnnoonanonnononcnnononcnnconanoncnnanennnnnnens 5 Finding A Record Nationally Held At Another Hospital ooocccccocccnccconcnnononcnnononcnnconanonconanennononons 5 Section 5 Creating a New Record ooooccccnnnccccccononcccnnncccnnnnnnncnnnononononnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnreninnnnns 7 Section 6 Entering Patient Information ooocccccnccccnccconccnnnncconononnnnnnnnnononnnnnnnnnnnnnononnnnncnnnnnononenannnnnnnnnnss 10 A
26. The Hearing screen comments box should be used to record any information on referral to audiologist reason not done etc SBR Clinical Manual Version 6 8 February 2014 Page 20 Routine Examination Tab Allows the results of the routine examination to be recorded For ease of data entry we have included a Select ALL Normal tick box as the majority of these examinations are normal lf required the user has the ability to then select a different value for an individual data item There is a summary box on the right hand side of the screen where details of the Initial examination are recorded You are able to print the results of the medical examination by clicking on the printer icon at the bottom of the page SBR Clinical Manual Version 6 8 February 2014 Page 21 Care Tab This screen is used when you wish to record data for a baby who requires any special neonatal or intensive care This screen has been designed so that it can either be used at discharge or perhaps more effectively it can be updated on a daily basis so that if and when the care is handed over to another consultant they are able to see at a glance the latest status of a particular baby qe Jl e Pee on ee eee i 1 pesiat Meenas Cum c M bamos do aitis negoetetute De 609 am dela amp 000 tun Rapes us adm o lbe 5 Come Po t 668 como Qe oe pre y T Ti wj gt i aas Jem d 1 e r m TT rcwe M
27. The background colour on The Print settings for Internet Follow the steps in Appendix A eee is being printed background displays down or there is a fault with helpdesk the SBR You have forgotten your N Please contact your local Password password Administrator If the SBR seems to be going slow here is a tip that you can try to improve performance Empty your browser s temp files After constant use of the browser this is the program you use to actually access the SBR system your pc becomes blocked up with temporary files stored in a temporary files folder It is wise to empty i e delete these files from time to time To delete the Temporary Files e Click on tsi Go to TOOLS Go to INTERNET OPTIONS Select the GENERAL tab Under the section Temporary Internet Files click on the button DELETE FILES Check the box Delete all offline content Click OK It may take a minute or two depending on the amount of TEMP files Once it is completed click OK ELE LEE Erro SBR Clinical Manual Version 6 8 February 2014 Page 39 Section 19 Frequently Asked Questions Q Baby has been transferred to a hospital outwith Scotland what should do with the record A The baby should be discharged on the episode screen to Facility Hospital Outwith Scotland It may be useful to say in the discharge comments where the baby went You should not use the Transfer screen for these babies Q A baby has been transferred from anothe
28. Universal Newborn Hearing Screening UNHS system which can be used independently from SBR however the two systems share the same unique SBR Indicator You may therefore be asked to transfer send records to other hospitals in other NHS Boards Please note that a training database has been used in the development of this manual therefore there are no real patient data displayed within the manual SBR Clinical Manual Version 6 8 February 2014 Page 1 Section 2 Log In To allow users to practice on the system there are two Scottish Birth Record SBR systems Live and Training To access these systems 1 Double click on the relevant icon on the desktop Train SBR or Live SBR 2 Enter a username and password Username Password Remember me Clear To exit click here or press ALT F4 3 Click on Login button NB If you tick the remember me box the system will automatically remember the last username entered so that you will not have to enter it again when logging back in The Training System Generic user names and passwords are created for each site within the training system Please contact your local SBR administrator or the Helpdesk to confirm the username for your hospital see Appendix D Contact Your training system password is training1 PLEASE NOTE The training system does not reside on a secure website therefore it is very important that you DO NOT enter any CONFIDENTIAL DATA The
29. aby 3032013 Not enterec ES 3 Garcia Baby Gen 13032013 Not enteres ai 2 gt ed x SBR Clinical Manual Version 6 8 February 2014 Page 3 Viewing Alternative Dashboard Displays The option for dashboard displays are e Current Records which have a baby s date of birth recorded but do not have a discharge entry this excludes still births home births and babies recorded as being born outwith scotland unless they are subsequently admitted to your hospital Note All births pre 2004 are excluded from current views e All Every record which is stored within the system at your hospital e Booked not yet delivered Any mum which has been booked into your hopital on the SBR but is still to deliver e Four weeks after EDD Any Mum that has gone 4 weeks or more past their EDD e CHls to be allocated SBR records which do not have a baby CHI entered on them e Invalid CHls SBR records which have an invalid baby CHI entered e g only 4 digits e Invalid baby dates of birth SBR records where the baby date of birth is entered at that time to make the baby over 10 years old or an incorrect date of birth e g 40 07 07 or 21 13 06 e By ward Everyone recorded as being currently within the selected ward When you first enter the system it defaults to display the current records You can change to any of the views mentioned above by clicking on the drop down box on the Dashboard View box User Alerts 4g Alerts Thi
30. are unsure or wish to edit the record details aet CHI Cancel iz E session mil time aut in 043 OO BM nene Z If any of the required data for obtaining a CHI is incorrect or missing you will be shown an error message indicating what is required to be amended prior to obtaining a CHI number see Figure 3 SBR Clinical Manual Version 6 8 February 2014 Page 32 E http Eest scattishbirthrecord scot nhs uk CHI Microsoft Internet Explorer provided by BT Yahoo Broadbai id CHI Registration Please check that the details below are correct prior to registering this baby on CHI Surname Egg Forename Baby sex Not Specified ou must indicate a sex for this baby Date of Birth 06 08 2009 Address First line of address must be present Postcode EH12 9EB Sorry but you do not have enough details for this patient to continue with the CHI registration process Back to Baby Screen E KE sesionwitmeoutim 0953 S mee A Click on Back to Baby Screen and add the required details e Once you have obtained a CHI number via the SBR it will automatically populate the CHI field on the Baby screen and you will not be able to edit this field unless you contact the Atos helpdesk or your local administrator who have the functionality to unlock the CHI When contacting the ATOS helpdesk you need to make it clear that you require them to unlock the CHI They do not need to know the reason why this is being requested
31. atient care to the community transferred to specialist non neonatal care e g cardiology or transferred to a hospital outwith Scotland Transfer when a baby is transferred to another Scottish hospital for neonatal care Note before a record is transferred it should be completed with all available information a transfer should be the last thing you do with the record as currently once you transfer it you no longer have access to it It is important to remember that the transfer facility should only be used if the mother baby has been admitted to you first If not then you must use the send facility Admission when a baby is admitted or re admitted to any ward within a hospital that provides any neonatal care this includes normal care Categories of care definitions based on BAPM 2001 Intensive Care ICU1 e Needing 1 1 nursing care by 405 equivalent Intubated 24 hours post extubation NCPAP 5 days old for any part of the day NCPAP 1000g for any part of the day NCPAP 1000g 24 hours after stopping NCPAP 29 weeks 48 hours of age Pre operative and 24 hours post operative Requiring complex clinical procedures Exchange peritoneal dialysis or treatment with Inotropes pulmonary vasodilator or prostaglandin 24 hours after stopping treatment with inotropes pulmonary vasodilator or prostaglandin e On day of death e Transported by a team including medical ANNP and nursing staff High Dependency Care previously
32. based on the wrong details and therefore invalid When NOT to Allocate a CHI on the SBR A warning will be displayed if the baby s DOB is over 2 weeks old see Figure 6 A baby of this age should already have been registered on CHI If the DOB is correct please contact your Child Health Department who will advise you of the correct CHI The number can then be manually keyed in to the SBR E http tesk scoktishbirthrecord scot nhs uk CHI Microsoft Internet Explorer provided by BT Yahoo Broadband ri x CHI Registration O Please check that the details below are correct prior to registering this baby on CHI Surname Egg Forename Baby sex Female Date of Bith 20 06 2009 The date of birth is aver two weeks ago Are you sure this is correct Address THE HOUSE Postcode EH12 9EB To proceed with this registration please click the Get CHI button Click the Cancel button if you are unsure or wish to edit the record details aet CHI Cancel El E Session wal time out in 0955 mee A Stillborns are not allocated CHIs on the SBR If your Child Health Department require one then they must allocate it Error Messages when obtaining a CHI Number On occasions you may be presented with an error message Most of these errors will have to be reported to the ATOS helpdesk However there is one error message that can be dealt locally and that is Error Code 0004 see Figure 7 this error is generated wh
33. cal Maternity Data Clinical Neonatal Data Baby Hospital of Birth Data Deleted Records Booked but not yet Delivered Coding Data ICO10 Coding Data OPCS4 Coding Data Episode History D ata This is the Clinical Msternity Dats Extract of the Scottish Birth Record Data By ves 2012 hd GO view Definitions Go Wiew Definitions This is the Baby Hospital of Birth Date Extract of the Scottish Birth Record Data DoB Excel Go When you delete an SBR Record it is nat physcially deleted from the database it is only marked as deleted By Year 2012 hd Go View Definitions This is an extract of SBR Records for when the Mother has been booked on the system but the baby has nat yet been delivered View Definitions This is the main Coding Data By vear 2012 E Go View Coding Data Definitions This is ICD10 coding showing all the codes used for your hospital This is OPCS4 coding showing all the codes used for your hospital Definitions This is the Episode History details showing all episode events for your hospital This is the Clinical Neonatal Data Extract of the Scottish Birth Record Data By Year Back to Main Dashboard These SBR data extracts contain up to the minute information which has been entered into the SBR or transferred automatically at your hospital The download is in a pure text format enabling you to import it into any programme for analysis Please note that you require Office 2000 to be able to
34. ce is the date the baby leaves Scottish Hospital care Tips for Transferring e Do not use the transfer screen when a baby is being moved between wards within the same hospital this should be recorded as a new episode e lf the baby is going directly from your hospital to another hospital do not discharge the baby from your care on the SBR just use the transfer facility e Once a record has been transferred you cannot access it unless the record is transferred or sent back to you e Ensure that you complete the record with as much information as possible BEFORE you transfer the record as once you have transferred it you will no longer have access to it e If you have transferred a record and have forgotten to add something please contact the designated SBR user at the receiving site SBR Clinical Manual Version 6 8 February 2014 Page 18 e f you have transferred to the wrong hospital please contact the Atos Helpdesk 0845 957 2 00 and someone from the SBR team will contact you to un do the transfer e f you want to transfer a baby that has been born to another hospital you must ensure that the baby has been admitted on the Episode screen first either an obstetrician paediatrician or midwife has been entered and the level of care has been entered e If a baby has been transferred to you you must admit the baby on the Episode screen before it can be discharged or transferred back e A list of records that have been transferred
35. cord who delivered a baby for a homebirth A On the Delivery screen fill in the Delivered by box with the persons name SBR Clinical Manual Version 6 8 February 2014 Page 40 Appendix A Technical Pre Requisites Internet Explorer Pre Requisites for the Scottish Birth Record Web Based System Version For the Scottish Birth Record to work version 5 5 or later 128 bit of Internet Explorer must be installed Printing To print the reports standard letters and forms your computer will have to be connected to a colour printer You need to ensure that you have print Background Colours enabled This can be found by e Right clicking on Go to Properties Go to Advanced Scroll down to PRINT OPTIONS Tick the box Print Background Colours Internet Explorer Toolbars The Scottish Birth Record runs in Kiosk mode which means the application opens up Internet Explorer without any toolbars visible However to print reports we utilise the Internet Explorer window which automatically has toolbars present AutoComplete to be turned off One feature of Autocomplete is that a dialogue box will appear asking if you require assistance completing the form To switch this mode off Open Internet explorer Go to the Tools menu Click Internet Options Click on the Content tab Under Personal Information click Autocomplete Deselect the Forms check box and the usernames amp password on forms box Click ok ocreen reso
36. d In order to obtain a CHI number the record you are sending must have e baby surname e baby forename default Baby is valid e valid postcode it must include a space e sex e baby date of birth e first line of address To obtain a CHI e Click on the ial button either on the main dashboard next to the record you want to get a CHI number for or on the baby tab of the particular record Note that if a CHI number for this baby has already been obtained via the SBR or has been entered manually into the relevant field on the Baby screen then this CHI button will not be shown e You will be presented with a screen that will show you the details you are sending to CHI to register this baby in order to get a CHI number back Please ensure that these details are correct if not please cancel go back to the record and amend where necessary When allocating a CHI number the background colour of the pop up box to clarify the baby s details corresponds to the gender of the baby Blue Boy Pink Girl y http test scottishbirthrecord scot nhs uk CHI Microsoft Internet Explorer provided by BT Yahoo Broadband CHI Registration Please check that the details below are correct prior to registering this baby on CHI Surname Egg Forename Baby Sex Female Date of Birth 06 08 2009 Address THE HOUSE Postcode EH12 9EB To proceed with this registration please click the Get CHI button Click the Cancel button if you
37. dsheets then contact the SBR Team See appendix D SBR Clinical Manual Version 6 8 February 2014 Page 28 Section 10 Contact The SBR helpdesk is maintained by Atos Origin and is available 24 7 You can contact them in a number of ways e Usethe link on the dashboard and complete the form e Email itservicedesk nhss ns atos net e Telephone 0845 957 2700 Atos Origin is the first point of contact if you require assistance They can help immediately with the following Find an SBR User Reset passwords Provide details of who you should contact to get a record transferred Add new postcodes to the system Unlock the baby CHI Any other problems or queries will be passed to the SBR team who will get in touch with you during normal office hours It is important that you do not use any confidential data in emails The SBR Identifier should be used to identify records that are being queried see Section 4 Finding Your Patient Record SBR Clinical Manual Version 6 8 February 2014 Page 29 Section 11 Logging Out Always click on s eC from the main dashboard to exit the system To close down the system click on Exit or press Alt F4 If you have any problems closing the system down please contact us If the system freezes you can use the AIt and F4 buttons together Remember that if you have not pressed the Update button on your current screen then any data items you have entered will be lost and not saved
38. e summary boxes on the right hand side of the screen By clicking on the Print room you have direct access to the Initial Baby examination report which can be printed off and filed in the case notes SBR Clinical Manual Version 6 8 February 2014 Page 15 Baby Tab This shows very similar data to the mother screen however it refers to the baby ost Delivery E od t on Bst Ferrera Bulb un las gt t Ounstans Park Alte alive t e fex fia Dod o Roxburghshire Leona Feorenorra Fou Cocos TOA IRA Cate of Birth Baer 20032013 Wie O ee t a t Berri with Liza area O Tire zt pen 13 47 seen A vu 1 Place Ber Homo Gerth Planned w acia Snn Borders General Hosptal w 0 Ses xt rmm aut 4 lat Sseahtec o Ep sc SIDO MN D Scottish v TIL P 16n4 1 Biisor lesa Precios Dot GF Fraction Goce UY Tre ineat Carte Ot Durata y Pee elroee TOS Sex GF GMC ne 3110137 Miras Mons sgr Syrorrs se ath Licther OF Detete a O Ce lero o CHI ecc Pane penis o laabon Case Fef bro Sverre zt inis Baty Uwebrth v o p Date of Birth Between the hours of midnight and 6am the Use today s date link beside the DoB field will be hidden forcing you to manually enter the date This has been introduced to reduce the number of incorrect dates of birth entered on the system for babies born during the night Synchronise fields Please note that the Address GP and GP practice code entered for mum can automatically popu
39. e to where you have your Internet explorer usually on their local disk C D Programme Files or Plus or Internet Explorer look for the explore exe e At end of address put space kspacehttps www scottishbirthrecord scot nhs uk note this has to be EXACT or it will not work Click on Next Type in Live Scottish Birth Record Click on Finish SBR Clinical Manual Version 6 8 February 2014 Page 42 Appendix C Data Entry Guidance Tips General e For security reasons if there has been no activity with the SBR for 20 minutes the system will log you out losing any data that has been keyed and not updated e When you enter any information you must click on the Wilkes ALI button to save the sy data Don t worry if you forget and change screen A warning q Verre ede duros a enn message will appear notifying you that data you have entered has E not been saved Click OK to save or Cancel to close the screen without saving tik Ot bc eave changes or Cancel bo arar o cw e Information Points y appear throughout the system hover your mouse over them to view e DO NOT use BACKSPACE on the keyboard if you are not clicked within a field data may be lost as this moves you back a screen e Where possible data items shaded in blue should be completed These are required for the National reporting e tis important to fill out all fields using correct grammar and spelling as the information recorded
40. ease do not add a new record contact the appropriate site to send the record to you or call the Atos Helpdesk Atos Helpdesk 0845 957 2700 and the SBR team will contact you for more details to transfer the record e Mum s surname address GP and GP practice will be assumed for the baby record If you do not wish GP Practice and or address to automatically populate the baby record then please deselect these by clicking on the relevant check box If you wish to change any of the details this can be done later see Entering Patient Information To add a new record for a baby without mother s details e Click on 5dd HeurHeonatsl R cord from the main dashboard e Complete all the mandatory fields marked with these are Surname Date of Birth and Post Code R seen Submit Record e Once the baby has been added search for the record as explained in Section 4 Finding your patient to enter the data SBR Clinical Manual Version 6 8 February 2014 Page 9 Section 6 Entering Patient Information Access to Patient Records Once you have created found your patient click on the button on the main dashboard next to the appropriate record to access it The following tabs will be displayed Mother Antenatal Birth Initial Exam Baby Episode Newborn Routine Exam Care Post Delivery VLBW only when the baby s birth weight is 1500grams or under or gestation is 32 weeks or under To access the tabs click on the appropriate head
41. en an invalid character has been entered in one of the essential data item fields PI test scottishtwthrecard scot nisuuk CP0_Action Micro Internet Expherer provided y Chi allocation Problem The system has beer unable to obtain a CHE number Please try agan ister f thes problem persists please contact the SBF Help desk on 0045 857 2700 doren Pert of the message below Back to Baby Screen SBR Clinical Manual Version 6 8 February 2014 Page 35 Section 14 Print Room The Print Room r tum a Li J LIII fo Aan spun up he meqiere nort q EE rr to mrt In 717 MN tote bi a i4 Dusia t we Eara sitas una Pae bam 60 IL J GPR apart Meyiti stien of Gerth f y i y r prvat 7 A Pi otr af y ont Merete of Fia tine Heston Recerd Matifs stren of Barth A NUT LL et umm pa terna arsit DPF tr d Ot be u Pays PS ep dra on e pac Eu Eus Lupin JP AU a The 16 Wa NP aon af mm Mim e Lun uuu xn a Mee seno i wen F s Data i d ti jm imme deste Discharge Lone Hewtarn Hearing Sarong Farm v ride gt jn sw ritum L1 v LIS Pr tata A e i bore Mes lt 1256 vin na i ne Newth Hegng Sc e Peo MERO beans LT P ss Ceodeng Output Mt den e CNA Outen Mid y Mae Cra bob cs rd The Print Room allows you to print reports and letters relating to a particular record from the SBR system To open the Print Room Click on a beside the appropriate record on the main dashboard Click on the document you wish to open
42. er These can be accessed in any order Some of the data items may already be recorded either as they were entered manually when adding a new record or the data was imported from an existing hospital system If you require clarification on definitions and standards for the SBR data items please contact the SBR Team see Appendix D Contact SBR Clinical Manual Version 6 8 February 2014 Page 10 Mother Tab This screen shows all the mothers details such as name address GP details etc It also has the facility to record the partner supporter details When a mother is transferred to you from another hospital please ensure that you overwrite the existing Hospital Patient Identifier HPI with the one from your hospital The previous HPI can be recorded in the Alternative Care Ref Number field New functionality will be written in the future to allow recording of multiple HPls Latest Recorded Past Medical and Obstetric History can be visible on the mother tab if these fields have been completed on the Antenatal Tab or you may wish to hide these details SBR Clinical Manual Version 6 8 February 2014 Page 11 Antenatal Tab This screen shows all the mothers antenatal details It contains date of booking past obstetric history past medical history family history etc Pon sess en 15 Careto M am c Partes peo royo 1 le eui T rore Pu E E S oer wre Prager ae ov ge Pe Peg ee no pe 3 j z
43. evel Whenever a record is accessed or any data item is added amended the date time and username are recorded on the audit log SBR Clinical Manual Version 6 8 February 2014 Page 38 Section 18 Fault Finding Possible Cause Acion O Unable to submit a new The mandatory fields have Complete all necessary fields refer record not been completed to page 7 The system has closed down The system has Log back in to the system if you want and returned to the initial log automatically closed as it has to continue inputting data in screen not been used for 20 minutes any unsaved data will be lost The system continually There appears to be a Inform your IT department crashes problem with the hardware the PC itself The data you have just The update button has not The lost data will have to be added added is no longer there been clicked and so the data again ensuring that the update has not been saved to the button is used database You are unable to view the The screen resolution on Please refer to the system pre entire screen your PC is incorrect for this requisites in Appendix A application A message appears saying Another member of staff in Once they have closed this record editing open You are unable to access the Please report the fault to the SBR section A dialogue box appears Your PC has the incorrect Please refer to the pre requisites in completing the form
44. for continuing care delivery If however the mum or baby has NOT been admitted but is going to receive treatment in a different hospital area then this is when you would use the send function To send a record send Click on the button located on the record accessed from the dashboard Click on confirm once you are sure the correct record is selected Select the correct hospital to send the record to Enter any comments relating to the sending of the record Surname Barlow Forename Baby Date of Birth 14 07 2006 Baby HPI L 22256393000 PA TU MEE Send Cancel If a record has been sent to you from another site you will see this icon on the main dashboard i If a record has been transferred to you from another site you will see this icon on the main dashboard SBR Clinical Manual Version 6 8 February 2014 Page 31 Section 13 CHI Interface The Scottish Birth Record system has the facility to obtain a Community Health Index CHI number for babies within minutes after birth If your hospital is participating in this functionality a CHI button will be visible on the main dashboard to the right of the send button The CHI button will also appear on the Baby tab 5 San Baby 24 12 2008 not entered dux l Suba Bacon Burt 29 09 2008 not entered C Luz Gi Door Sm not entered EMAIL E mm oo RS Baby Green 29 09 2008 19 eme ALL dx E Dor Baby Gsen 29 09 2008 not entered G duoc a uu
45. i tem eres Zo e 12 a Dew pi CO feb 3 n e a ef m v Am 2 wf 8 I 13 s 5 Pee iae io S d The Mother s age is automatically calculated at time of data entry of mum s date of birth on the mother screen If you do not know the exact day or month when entering dates please default to 01 01 and the year The BMI is automatically calculated once you have entered height in metres and cms and weight in kilos Past Obstetric History Due to increased use of the SBR many mothers have been through the SBR before and had their Past Obstetric History POH recorded Therefore for mothers with subsequent pregnancies you will not have to enter the POH details again They will be automatically populated for you however you are able to edit these if required It also allows for an unlimited number of entries Estimated Date of Delivery box a message will appear to remind you to fill this in if this is not entered before you try and click onto the next tab It will not prohibit you from clicking onto the next tab it is purely a reminder SBR Clinical Manual Version 6 8 February 2014 Page 12 omoking alcohol and drugs SBR Clinical Manual Version 6 8 February 2014 Page 13 Birth Tab This screen covers all the details relating to the delivery of the baby It is split into 3 sections labour delivery and baby Labour Done of Ageiaio to Lacow Ward Tira cl Aria So LOC Wed Onset taasis Aagrers
46. late the baby screen from the Mother tab and vice versa by clicking on Synchronise with Mother Baby Address GP Details You can however change these details if necessary Homebirths and Place of Birth Homebirths can be recorded by selecting either Home Birth Plan N K Home Birth Planned or Home Birth Unplanned in the Place of Birth field The baby can also be admitted as a homebirth on the episode screen by selecting Level of Care Homecare and then select Discharge Type as Homebirth The record will remain in the current view of records unless the baby is discharged from care If care is provided for a baby who was born outwith Scotland please remember to record place of birth as Born outwith Scotland Hospital of Birth The Hospital of Birth field is a mandatory field A pop up box appears if a user tries to move onto another tab without entering a hospital of birth asking the user to select a value for the Hospital of Birth field Hecording Stillbirths and Neonatal death All births should be recorded on the SBR To record stillbirths change the Outcome of this Baby to stillbirth This field automatically defaults to livebirth unless you change it Neonatal deaths can also be recorded in this field SBR Clinical Manual Version 6 8 February 2014 Page 16 Episode Tab This screen details the care given to the baby and by whom i e admissions to other wards such as special care discharges f
47. lution to be set at 1024 x 768 To change your screen resolution Click on Start at the bottom of your screen Select Settings Click on Control Panel Double click on Display Go to the Settings tab Under Screen area click on and drag the slider to 1024 x 768 LE o o2 E 5 Ax Click Apply Notes e Ahigher resolution reduces the size of items on your desktop e A lower resolution increases the size of your desktop e Your monitor and display adapter determine whether you can change your settings or not Any doubts please contact your IT department SBR Clinical Manual Version 6 8 February 2014 Page 41 Appendix B Setting Up Icons on Your Desktop Setting up a Training SBR logo on your desktop Firstly ensure that your PC is linked to the NHSNet Right click on the desktop Select New Select Shortcut Create shortcut dialogue box appears browse to where you have your Internet Explorer usually on your local disk C D Programme Files or Plus or Internet Explorer look for the explore exe e Double click or OK At end of address put space kspacehitp test scottishbirthrecord scot nhs uk Click on Next Type in Training Scottish Birth Record Click on Finish Setting up a Live SBR logo on a desktop which is linked to the NHSNet Firstly ensure that your PC is linked to the NHSNet Right click on the desktop oelect New Select Shortcut Create shortcut dialogue box appears brows
48. matus Cer Fen ead es Ort awe Finn ipt iz mu 1 Sereening event bed Spei Pos sem e or w mu o ni sue an Sota de aacra Toere sa en B T I m te tars Dis Haates AI orf a anna ten iD MUN p rare Aapeli lew S pasl an bisai Les o LIT TIT heme Within this screen there are a number of information points B These icons give you additional information regarding the data item being recorded To access the information point use the mouse to hover over the icon and the message box will appear Tips for the Newborn Tab 1 If a data item appears on more than one screen For example OFC appears on the Delivery screen and again on the Newborn screen When you enter data into one it automatically populates the other The Max Bilirubin field is the highest recording within 28 days of birth If you enter a recording of 121 on the second day of life and then the following day the Max Bilirubin is recorded as being 124 then this field should be over written with the 124 recording The Lowest Glucose should also be over written with the lowest glucose measured The birth weight should be entered in grams Birth weight must be entered as 4 digits and preceding zeros should be entered if the weight is less than 1000 g In addition the Subsequent Weight field also has the addition of a date field so that where possible the date of the latest weight should be entered
49. mit access to enable further data collection and sharing of patient information SBR Clinical Manual Version 6 8 February 2014 Page 24 Section 7 System and Password Administration To access the Admin screen click on 5 Admin from the main dashboard This screen allows you access to the following functions User Administration User administration Automated imports Record movement Tools Your view of this section will vary depending on the type of user you are e Standard User This is where you can change your password e Admin User This is where you can change passwords introduce new users change or update user details reset passwords and administer nurses midwives on the episode screen and also add any new wards Only users with administrator rights to SBR can access this part of the system There is a separate manual that explains how to work the functionality It is available to administrators SBR User Manuals and Quick Guides These are available on request Automated Imports If you are automatically sending files to the SBR database then you can access your own Automated Import Log This enables you to view a log of the files you have sent in how many records were in each file and if it was successfully imported into the SBR Hecord Movement This allows you to view records which have been e Transferred Records e In Utero Transfers e Sent Records SBR Clinical Manual Version 6 8 February 20
50. nctions are described in e Contact detail later e Logging out Posee wies tion 20 EA 18 yow 724124 w bob qoc 0 wu Ji sco Ben coe 9 mo sca O The lower section see screenshot below provides access to your patient records It also Provides access to the print room Provides ability to delete a record Provides ability to send a record to another location Indicates the transfer sent status of a record Provides access to the CHI interface where implemented If a record has a blue background the baby is a boy if it has a pink background it is a girl and a yellow background indicates that the sex of the baby is unknown A light grey background with grey text indicates a record which has been either Transferred or Sent to another site A dark grey background with black text indicates a record over nine months old A dark blue dot next to the baby s forename indicates a stillbirth or a baby that died during care A count of records together with the number of pages is provided for information Again these are described in detail later tet o toot a im Aude Do Ra E 09m 37 az pa os A ET Pepper Bady 2003 2013 Not entered se oars Sas Purple Penelope 20 03 2013 Not enterec ES x Foster Baby 190372013 Not entered at iE 12 PMA gt as Baby y 18032013 Not enterec Gaa gt x n ge T Y gr Baby Eir 15032013 Not entered x iS E a 1 13 N T Bobby B
51. o be added for the most current episode Place of Birth Home Births Born Before Arrival amp Born Outwith Scotland Homebirths can also be recorded by selecting either Home Birth Plan N K Home Birth Planned or Home Birth Unplanned in the Place of Birth field on the Baby tab The baby can also be admitted as a homebirth on the episode screen by selecting Level of Care Homecare and then select Discharge Type as Homebirth The record will remain in the current dashboard view of records unless the baby is discharged from care If care is provided for a baby who was born outwith Scotland please remember to record place of birth as Born outwith Scotland Discharge Letters Immediate Discharge Letter Neonatal Discharge Letter and Handover to Health Visitor Letter can be selected at the bottom of the screen These can also be found in the print room from the dashboard SBR Clinical Manual Version 6 8 February 2014 Page 19 Newborn Tab This screen shows the baby details such as type of feed congenital anomalies and screening f M nz Jf lo 22 E emen fla O p Mas Mate wee o Praha tt com o Chr ere o bet senes Tar Tom heegt Comm agli Feet s hage Pare que ca ero us gt Aem feet Wow O heed at d 2 FT Oat i CELES Vitamin h teat wel OE Du n Eae ias Prud ete a bedava Dad Hie be inl Congenital Anomaly Pengurte ae ete Piera apo at gud a
52. ooooccccnccccccooonnccnnnnnnononononcnnnononononnonnnnnnnnnnonnnnnnnnnnnnnnononanennnnnnnns 40 Appendix A Technical Pre Requisites cccooooccccoconnncoconcococonnonconononconannnnononnnnnnnnnnnnonnnnnononnannnnaneness 41 Appendix B Setting Up Icons on Your Desktop ooocccccccccoccnnccononnconncononncononononncnnnnononnrnnononannranononnns 42 Appendix C Data Entry Guidance Tips sssssesseisssseessseeesee nennen enne nnne nennen nnn nnn nnns nnns 43 PODENGIXID COMAC siii iote ente A oec ie tem ceto t ex velo lidia 46 Apbenaix E GlOSSANY aras lia odiaba 47 Section 1 Background amp Introduction Welcome to the Scottish Birth Record SBR Clinical User Manual There are two separate yet dependent modules to the SBR system There is the clinical module which can be completed by midwifery neonatal and paediatric staff as well as administrative staff where appropriate This then feeds the relevant data items into the smaller coding module The coding module is then amended and checked by trained coding staff Amendments to clinical data items by coding staff do not change the entries made on the clinical side The coding staff also add any diagnostic codes ICD10 and procedural codes OPCS4 where appropriate and submit the record to the national central database Until 1996 every baby was entered onto the SMR11 scheme At that time it was decided that details of healthy babies should reside on SMRO2 ma
53. r Scottish Hospital but there is no SBR What do we do A Before adding a new record either contact the relevant hospital to transfer the record to you or log a call with the Atos Helpdesk and someone from the SBR Team will contact you to transfer the record to you The SBR team can check the whole database in Scotland to search for records Q have been into the system previously but today am told that do not have access What can do A Firstly try re entering username and password If this doesn t work you can try resetting your password via your administrator If this still doesn t work please contact the SBR team Q Can babies born outwith Scotland be recorded on the SBR A Yes they can Simply start a new record adding as much information as you can On the Delivery screen simply select Born outwith Scotland in the Place of Birth field Q How can forward a record to another site for postnatal care if the baby has been discharged home from our hospital A In this instance the record can be SENT to another site using the new send facility on the dashboard This will enable the receiving site to access and add any additional information such as hearing screening results Remember that once you have sent a record you will no longer be able to access it Q What do do if have accidentally transferred a record to the wrong hospital A Contact the Atos Helpdesk and the SBR Team can rectify it for you Q Where can re
54. r continued care If they have not been admitted to your hospital and you require the record use the send facility instead To transfer e Click on on the Episode screen e Complete the date click on the Use Today link to use today s date e Select the hospital the patient is being transferred to To select the hospital quicker type in first letter of hospital and the box will be populated with the full name If there are several hospitals beginning with the same letter continue to hit the relevant key the first letter of the name until the Hospital you are looking for appears e Enter who carried out the transfer and add any appropriate notes Transfer e Tocomplete the transfer click on e Tocancel the transfer click on By transferring the baby s record on the SBR you are changing the access rights to this particular record The new location will have full read and edit access At your location on the dashboard screen you will see the record details however they are greyed out lt will detail where the record was transferred to when and the username of who transferred the record This record will no longer be accessible until it is either transferred or sent back to your site Note that if the baby is transferred to England this will be treated as a discharge Discharge Type Facility Hospital Outwith Scotland as the Scottish Birth Record system is not available outside Scotland The discharge date in this instan
55. r the Reasons for Instrumental Delivery field This is called the DDI Interval mins field The field is also included in the Clinical Maternity download export from the Export tab Between the hours of midnight and 6am the Use today s date link will be hidden forcing you to manually enter the date This has been introduced to reduce the number of incorrect dates of birth entered on the system for babies born during the night Apgar Scorer Total scores can either be entered directly or individual scores can be recorded via the sere link NR should be selected if the Apgar score has not been recorded RR should be selected if the baby was receiving resuscitation and the Apgar score could not be calculated Apgar Score Calculator at 1 Minute Carpi Georg SBR Clinical Manual Version 6 8 February 2014 Page 14 Initial Examination Tab Allowing you to record the results on the initial physical examination carried out on the baby such as Vitamin K given cord check chest examination etc LZ L2 EB ED LL LI asm parisi Neonatal Cars We ES is Toda dal Tewe pu 7 on Sam For ease of data entry we have included a Select ALL Normal tick box as the majority of these examinations are normal lf required the user has the ability to then select a different value for an individual data item If there has been any information entered onto the medical exam or the care screens it is seen in th
56. rom wards and the hospital and any transfers from other hospitals etc lt also allows you to transfer the record to another hospital if the baby is going to receive ongoing care at the new hospital Date Ward Level of Care Consultant Obstetrician Conmeultant P sediatician Midwite Muros hm e hs hes rte hier 1802 20 0 pirs Speci Carm Caoire Claes pat 1 80272010 siren treneterrec from Aperdjeer Matem y H ora to Hwy re H 1702720 0 Primo ee wand High Dependenry Ded Abramovit Hita Abrs cont Discharge Letters e rumes Discharge Letz e Neonaty L scharge Leger A tangate io Henin Wete ute penei Data recorded here is for baby activity only To add an episode e Complete the boxes within the Admission Internal Transfers for this baby box at the top of the screen the green area e If you want to use today s date click on the Use Today link above the date field NB the admission date defaults to the baby s DOB e You must have either an obstetrician paediatrician or midwife selected to record an episode e Click on MAMA to save the episode The last episode added would always be populated in the Admission Internal Transfers for this baby box to add a new episode overtype the existing data and click on Update To add a discharge e Complete the Discharge from hospital for this baby box at the bottom of the screen the pink area e f you want to use today s date click on
57. s will warn users to the following e Identify any booked but not yet delivered records that are more than 4 weeks past the recorded Estimated Date of Delivery e CHls to be allocated SBR records which do not have a baby CHI entered on them e Invalid CHIs SBR records which have an invalid baby CHI entered e g only 4 digits To open the alerts click in the logo above and select the appropriate alert you wish to view SBR Update Log Clicking on the SBR update log will take you to the SBR website Details of version updates as well as User Manuals and Quick Guides can be accessed here Baby Death Indicator A stillbirth or a baby death is indicated on the dashboard with a small dark blue circle next to the baby surname SBR Clinical Manual Version 6 8 February 2014 Page 4 Section 4 Finding Your Patient Record The record you are looking for may already exist on the SBR Records can be manually keyed by another user imported from an existing hospital system or if the baby has been transferred to your hospital in utero It is therefore always advisable to ensure the record does not already exist on the SBR before adding a new one by searching the records held at your hospital site If the baby was born or has been treated at another hospital the record may still be with this other site please use the national search tool to locate the record and then contact the relevant site or the helpdesk for further assistance See Appendix D
58. stise Tr 24e w c See PS A Legi tu and Sta Yi amp amp cowca s Dowrcece w Cate Tire tape e e ieee ow m Mire 1 Mira mi there 18 111294 Pair Nelis Tias selec p eccrine Scirel 7d 30 r4 Jean ater ter uo were C Aa ena O inserhenz D esa c O coros pos dei O etimo O res C Bitis L Debver O ewe C rnc O 714556 10001 BT ugi MIO dit Fiame acest O ony ere et o liat 10 5201 Delivery Pauw 1 Emergency CS M hiure el Cesar of Births V Detweres by Pauline Devon Lera Seire for wv mace we N T de Dies v ts RI Emoto 95 Pr Lean e FES Sme OD interval imis 19 See Closure pase pinnis v j Gioca Lost In A Po 51834 Po Suge Demen m o V Correr V Meregeves Compiicators Baty 2003203 Langit Crown Birt Weegee o Date of Bit CRUEL t2 errar v eel E Y EH E T Trees ses te Segui Saneiprion OFC om 0 capta tie Dorders General Hospital v 7 Se Octet O mO GO sasen O Q Cos Bisse iens Pe Zo Bara bian Aerial Pr Aertel Bare Erasm The Delivery box will give you the option of choosing the various different types of deliveries including Caesarean Sections If you need to add a reason for the CS this can be entered on the Delivery Complications free text box This can then be run off in a report from the Export tab Clinical Maternity data The time taken in minutes from the decision to carry out a C section to the actual time of the C section can be recorded unde
59. t yet delivered BBNYD You can also enter data you are searching on and click on the Search View button to find individual records in those groups Add Mew Neonatal Record Current Search View Surnarne Forename alt LL LI Mum Baby C Bath if Finding A Record Nationally Held At Another Hospital You have used the above search tool and have not found the record you wanted locally at your hospital site The record is possibly at another site for a range of reasons i e the baby s care was transferred to a new site and the record moved correspondingly Alternatively the mother may have given birth in a Hospital which was not her local hospital and the record was required after the birth for supporting the mother Postnatal SBR Clinical Manual Version 6 8 February 2014 Page 5 As mentioned in the introduction another application has been added to SBR the Universal Newborn Hearing Screening UNHS system which can be used independently from SBR however the two systems share the same unique SBR Indicator You may therefore be asked to transfer send records to other hospitals in other NHS Boards and this maybe another reason why you can not locate your record The national search is there to help you locate a record Once you have located the record through the national search at another hospital site you can contact the helpdesk or local site and ask for the record to be moved to your site
60. ternity and the SMR11 would be reserved for sick babies and those with congenital anomalies However this did not prove successful and there was confusion over what constituted a sick baby There was also an unacceptably low level of reporting of congenital anomalies The SBR has replaced the SMR11 reporting scheme and every baby born in Scotland will have one and only one Scottish Birth Record All sick babies born from the 1 April 2003 have been entered onto the SBR system The SBR system provides the functionality to record all of a baby s neonatal care in Scotland including readmissions and transfers in one record The growth of Internet technology has allowed us to devise a web based reporting scheme Although the SBR is a web based system it does not reside on the public Internet instead it is on the NHSNet which is the NHS private version of the Internet All interactions are password protected and the system has a full audit trail Further work is planned to build on the SBR s ability to share data This will bring additional benefits to areas such as direct patient care service management planning and research Already the SBR extracts data from clinical maternity systems and Patient Administration Systems and can be used to interface with the system which generates Community Health Index CHI numbers 62 of babies in Scotland already get their CHI number this way Another application has been added to SBR the
61. ther Details Stage 2 New Mother appears Complete as many fields as possible including the mandatory fields marked Vara wr lar o9 tat n Cn Nem Pusi eee Itasa abest ldeci nn ate of Euh ettari o A erialas ane bel Mes Sete mE Lab of Si fee o Pros ee ts Lusrated Derer ate iE Ins f v Cw harri af darius wagers m ETTTM Mother is listed correct match The screen displays a possible match If the data is incorrect click on Back and repeat steps above for confirming a mum or creating a new mum If this is the correct Mother Select Add new baby to this Mum The mothers details held on SBR are displayed to start a new record for the new birth see below SBR Clinical Manual Version 6 8 February 2014 Page 7 Confirm e Confirm the data returned and update if necessary e fthe data is correct click on Confirm e Once the Mother has been added search for the record as explained in Section 4 Finding your patient to enter the data If the mother has a multiple pregnancy Save Go to the bottom right hand corner where there is a number of birth expected drop down box Enter the required option i e twins triplets etc then add new mum The system will then automatically create the number of records required automatically SBR Clinical Manual Version 6 8 February 2014 Page 8 Notes e f the mother has transferred to your hospital during this pregnancy pl
62. view the data from this page To download the information Click on Export Data from the main dashboard Select the year beside the appropriate dataset you wish to extract i e Clinical Neonatal Data Click on Go If no year is shown click on the name of the dataset you want to download Select if you wish to Open the data from its current location or want to Save it to a secure location Note once downloaded the data becomes your responsibility This data must be treated with care in accordance with data protection legislation Please remember that the data will remain on the hard disk of your computer after you close the SBR and that data may still be retrievable even after deletion The following downloads are available Clinical Maternity Data All maternity data extracts based on a particular year for current hospital Clinical Neonatal Data All neonatal data extracts based on a particular year for current hospital Baby Hospital of Birth Data Total numbers of babies born at the current hospital within a selected date range and showing current record location Deleted Records A list of all records that have been marked as deleted for the current hospital Booked but not yet delivered Records where mum has been booked on the system but baby has not yet been born Coding Data All coding data based on a particular year for the current hospital ICD10 Coding Data A record of all the IC

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