SBR Coding User Manual
Contents
1. Date Level of Care Obstetrician Paediatrician Midwife Nurse Codes ICD10 Code Description Stay No Notes OPCS4 Code Description Consultant Date Stay No SBR Coding User Manual Page 332. Add new record Accessing alternative dashboard displays Searching for records System and password administration Reports Exporting Data Contact Logging out User alerts where records require attention SBR Update Log These functions are described in detail later conta tus Hempltas Y Y renga um tom M SETA 9m pew 1224 P ae Ao a Fem 109 DA o NHS j zee See See sa e 3 Highland o3 7 o i D T C EMI The lower section provides access to your patient records It also provides e Access to the print room e Indicates the transfer sent status e Contacts who can delete a record of a record e The ability to send a record to e Access for submitting records to another location ISD e Access to the CHI interface e Indicates the coding status of where implemented each record 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 bae S mcamm bet mom fot
3. National ces Scotland The Scottish Birth Record Coding User Manual Version 6 8 February 2014 Table of Contents Section 1 Background amp Introduction oocccccccccnncconcnncoconcncnnonnnnnnonnnnnononnnnononnnnononnnnnnnnnnnnonanennnnonens 1 Seco Lorraine eee eee 2 TAS Tala NE T utl 2 The Live SYSICM 2 Section 3 The Coding Dashboard ccccoocccccconcnncconcnncocononcnnoncnnonononnnnonnnnnonnnnnnonnnnnnnonnnnonnnnnnnonanennnnonens 3 Viewing Alternative Dashboard DiSplayS coooonnccncccoconcnnccononncnnnonnonncnnnnononncnnononannnnnnnnnnnnnnnononanenns 4 WSS ATTENDERE RR DR T 4 Js NER NR TEUER 4 Baby Death ML erue ER RT 4 Section 4 Finding Your Patient Recoro occcccccccnncccoccncocononcnconcnnononnnnnononnnnononcnnononnnnnnnnnnnnonanennnnanens 5 Section 5 Adding a New HOGCOIC unite rene peser nba tu aerei ena rice 7 SECTION 6 Opening RECOM sica sai dotis e tea ii Uthass Ue 7 Section 7 Multiple IAS mem x u 8 e e O E 8 Section 9 Deleting a Record oocccccccccncccconcnnoconcnnonononnnononnnnononcnnnnonnnnnnnnnnnnnnnnnnnnnnnnnnnnonnnnnnnnnnnonanennnnaness 8 Section 10 Sending TECONA iusciusuiadit dens iskisbsbactbebks EAER AEA E bus d axi EAEE Mb c R KURSE 8 Section 11 Entering Patient Information ccccccccnncccnnnnccconcnnnconnnnononnnnnnnnnnnnononnnnononnnnnnnnnnnnonanennnnon
4. 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 currently being 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 1 D E Alerts This will warn users about 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 CHI s to be allocated SBR records which do not have a baby CHI entered on them e Invalid CHI s SBR records which have an invalid baby CHI entered e g only 4 digits 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 Identifies a baby stillburn or baby death on the dashboard as a dark blue dot next to the Baby forename 141 Recoods in total Page 3 o1 Baby DOS M Som 05 06 2008 o Y ments elg Baby Surname Forename Baby mus Baby June Hospital Pater ID CH not entered Section 4 Finding Your Patient Record The record you are loo
5. 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 not 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 v Current Search View Surname Forename alt AAA Mum C Baby C Both if SBR Clinical Manual Version 6 8 February 2014 Page 5 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 As ment
6. 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 If you have any problems or need any assistance to allocate a CHI number please do not hesitate to contact the SBR Team via the Atos helpdesk Section 20 Audit Trail There is an activity log incorporated into the system at data item and username level Whenever a record is accessed or any data item is added amended the date time and username are recorded on the audit log Section 21 Fault Finding Possible Cause Action record not been completed refer to page 8 The system has closed down The system has automatically Log back in to the system if and returned to the initial log closed as it has not been you want to continue inputting in screen used for 20 minutes any data 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 added The update button has not The lost data will have to be is no longer there been clicked and so the data added again ensuring that has not been saved to the the update button is used database entire screen your PC is incorrect for this pre requisites in Appendix A application A message a
7. Dee teetgetel Porsi E Che uet we AA m j Moneypenny Baby 2 1 03 0013 Not entered ua ox J Buio Serah 20 03 2013 Nor entered gt x we ET ula Davey Michael 20 03 2013 Not entarec reu p x ua loe pala es eee ae too AAA A 1 n 8 numo 1 nd Grange Baby k 20032013 Not entered a xx ua t Janes Ollia 20 03 2013 Not enterec aw y xu GO I T ik a e M M cce vt _E _ M ese Bioggs Baby 194032013 Not entered PUE y m Ch qu gq o MM M 4 C j 6 03 2013 Not v 200 Baby 19 0532 13 Not entered aw 53 uu i e gt n HDD D onn 9 03 2013 Not f s rj D i Baby 19 03 2013 Not entered en 5s un i Ez 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 the system but is still to deliver e Four weeks after EDD Any Mum who 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 CHIs
8. OES mU sce ici atico le iras idea 20 Secon TG A e oo 3 21 Statistics fom The SB Andante dett MM EE 22 Section 17 COMAC m R 23 Section 18 Logging lla a m 23 Section 19 Chal nteraee uu ita a R ld 24 Keep EXISTING AL DU ON aros ER 24 ANOCHE NeW El DUO ird LER QU odi DON V bL ES p dot Ha owes ga Du ade aed v ve e dete i Dr d De abet E dva 24 iere Mei mI TT TTE 25 Secon 230 AUI Trakea Ent ev D Spree a enne s cua Ei quisesapeE uto reacts 25 Section 21 Fault Finding iessen a a e a a e a a RA aeaa E TER 26 Appendix A Technical Pre Requisites oooccococoncoccccononccconnncononcnnnnnnnonoonannnnononcnnononnanennananess 27 Appendix B Setting Up Icons on Your Desktop ccccccccccncnncccconcconncononncononononnnnnononancnnnononanenos 28 Appendix C Data Entry Guidance TipS cccoooonccnncccconconnccnnoncnnnonnnnncnnnnonnnncnnnnononnnnnononnnnnnnenonannnss 29 dle umo PA o E UTER 30 Postcode amp Address A e epe C ee Ten Lo Hi teo eu ope ESL EA ue 31 Append D eG losSsabyzmu tinier PUEVE eate nte pa vo deu iar MEM Pu cv Su UE d Du ra DUO d V UU TC 32 Appendix E Blank Coding Output Form sos susc saswo so itur ra 33 Section 1 Background amp Introduction Welcome to the Scottish Birth Record SBR Coding User Manual There are two separate yet dependent modules to the SBR system There is the clinical module which can be com
9. Record Please note that for multiple pregnancies each baby will require a record If a new record has been added for the Mum via the clinical section the number of baby records required should already have been added by the clinical users New Scottish Birth Record Baby Details Coding Hints e Click on 5etedavs Late to default the baby s date of birth to today s date e There is an 9 Information Point next to the Birth Weight field This field should be entered in grams and stored as 4 digits Preceding zeros should be entered if the weight is less than 1000g e f the connection is slow please do not keep clicking on the Submit Record button as this may create multiple records Section 6 Opening a Record Once you have entered records into the system an abbreviated record will appear on the dashboard including details of Baby Surname SBR Indicator Baby Forename Baby DOB and Baby HPI where appropriate Simply clicking on the Code button next to each record will take you into the main body of that record If there are a lot of records on your current dashboard you will need to use the surname HPI search facility to find the record you want SBR Clinical Manual Version 6 8 February 2014 Page 7 Section 7 Multiple births To record multiple births a separate record must be completed for each baby If a new record has been added for the Mum via the clinical section the number of baby records required should alread
10. Screen The Very Low Birth Weight VLBW screen is where information on CRIB and Morbidity data are recorded This screen only appears if the baby meets the VLBW criteria the baby is either less than 1500 grams or if they are less than 32 weeks gestation Completion of this screen is not mandatory for the Information Services return and only needs to be completed where the VLBW study is being conducted Section 12 Submitting and Retracting a Record Once you have finished coding the record you can submit it to the SBR database and it will be removed from your current view on opening the SBR Records can be submitted when they are partially coded or fully coded If you submit partially coded records they can be retracted at a later date fully coded then submitted again To submit a record 1 Click on E SBR Submission I xX Is coding complete Yes No Cancel http jtest scottishbi r Internet Yes o 2 Click on for fully coded records and for partially coded records Once you have submitted a record and realise you have more coding to do 1 Search for your patient See section 4 Finding Your Patient Record 2 Click on Retract under the Fully or Part Coded icon Retract 3 Open the record as detailed above Section 13 Print Room To open the Print Room En Eu Click on beside the appropriate record on the main dashboard Click on the document you wish to open it wil
11. 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 Alt 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 The SBH 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 Section 19 CHI Interface The Scottish Birth Record system has the facility to obtain a Community Health Index CHI number for babies shortly after birth If your hospital is participating in this functionality a CHI button will be visible on the main dashboard To obtain a CHI e Click on the CHI button on the main dashboard next to the record you want to get a CHI number for 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 available to you 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 wil
12. remove button next to each line and start from the top down so in this case it would be the discharge that would be removed first Homebirths Homebirths can be admitted as a homebirth on the episode screen by selecting Level of Care Homecare and then select Discharge Type as Homebirth Homebirths are also recorded by selecting either Home Birth Plan N K Home Birth Planned or Home Birth Unplanned in the Place of Birth field Transferring a Patient Code_Episode_Transfer Microsoft Internet Explorer Transfer this baby s records to another location Date Use today Hospital Transfer bw Hotes IIS 00 INN HB Please note that once this record has been transferred you will no longer hawe access to it A list of transferred records can be downloaded on the Admin screen This screen is used when the baby is being transferred from your hospital to another Scottish hospital for continued care If they have not been admitted to the other hospital i e only visiting another hospital 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 hi
13. 20 12 Thes baty has been discharged Dezcnarge Type Home Bague Normal Hassan All Hornal Hassan Ali High Dependency Hassan Ali Special Care Episode Status Patient Discharged on 12 09 2012 Home rerater Pe coher to arcte Socr Someta scores soccer E O 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 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 the Use Today link below the date field e Select the Type of discharge e Click on WELL to save the discharge The discharge will be added to the top of the episode history box 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 If you want to remove a line in the Episode History box then simply click on the
14. 377 16137 3205499 Jonas Neil North Berwick Heal Centre St Bealdrad s Hond North Bereick EH394FP 7 01520 892155 77036 4746391 Jones Valene Ess eid Medical Practice Eastheld Farm Rood Penicuk EH2ZBBEZ 01 958 675575 78109 2983390 Jones len Feuldhouse Health Centre Blsckfeulds Piece Fauldhauze EH479AS 01501 770282 78255 4612067 Jones Lucy Howden Haalf Centre Howcdan Road West Livingston West Loftean EHSSSTP 01506 423000 Selen Find e Click on to the left of the GP Practice Code field e Search on either the GP s surname and or the Practice address Click on Seereh Highlight click on the relevant entry from the list presented of possible GPs and Practices Click select The GP Practice Code and GP s GMC number are now automatically completed Hints amp Tips for Searching e Forsurnames 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 When searching on the practice address enter details in the first line only see below If 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 Postcode Address Fin
15. NP and nursing staff High Dependency Care previously 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 Appendix E Blank Coding Output Form Baby Identification Surname GP Practice Code Address Forename Ethnic Group 2nd CHI Number Forename DoB Hospital Patient Id Postcode Sex Birth Details No of Births Phototherapy Hearing Screen Estimated Gestation Max Bilirubin Blood Spot PKU Birth Weight EE OFC Blood Spot CH Place of Birth EE Length Crown Heel Blood Spot CF EDD Lowest Glucose Blood Spot Repeat Apgar Score at 5 Subsequent Weight Congenital Anomaly mins Resuscitation Subsequent Weight Date Notes on Congenital Anomaly Feed on Discharge Other Physical Problems Comments Episode Details
16. SEB EH12 SEB Cancel SE ert E The above screen means that the data you are sending to the CHI system appears to match an existing record please check carefully before you proceed 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 f 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 Cancel button e f 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 based on the wrong details and therefore invalid If any of the required data for obtaining a CHI is incorrect or missing you will be shown an error message indicating what you are re
17. aie of Delivery EDO 16 10 2011 ii IES Senadiesor Ni Facial Oxygen A A O Presas no x Feet Or Ducere Breast only RE Harig Bower Lem Pass Pi ca 11 10 2011 15252 Da av on Art Pass bd Ries ser Done om 13 10 2011 srta Tos mise se Done 2 rate 13102011 sarissa zm messzeecr Done S cae 13 10 2011 eae teers zm Sized Sect feces Done j 724 13 10 2011 cae toners Dee Procedures Any notes on congenital anomalies made by clinical staff will appear under the congenital anomaly problems at discharge section The Special Neonatal care box shows any diagnosis or procedures entered by the clinical staff This information may be useful to you when you are adding ICD10 and OPCSA codes to the record Codes Screen beauistst Rue aon eee Dihet Other preterm mntanta Gatari papas of newborn unspes feit i QPL24 Lalo Gasiunss Mes Man Gama Othar Catsalara 214 a 2339 Umapectiod other blood transhuseon rayud n Ahmed i Remove n2 UA 20 1 Pi 3 d ama SAA coc ovd updated ver c se hy This screen enables you to enter ICD10 and OPCSA codes for each stay the baby has in hospital It is important to check you are coding the correct stay number to check for the dates of each stay please refer to the Episode screen The screen above shows this baby has 2 stays A stay is classed from admission to discharge from hospital Therefore each time a baby is readmitted to hospital afte
18. 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 Record Movement This allows you to view a list of records which have been in utero transfers transferred or sent from your hospital via the SBR Section 15 Reports Clicking on parc from the main dashboard allows access to reports and graphical analyses of the data entered into the system Scottish Betti Record for f dere General Haapstal 150 SOR Team piegati eomm Meee i Ade mw e j wm SeperiOmta j Couwm j Jl j Borders e ensi o Clam Reporta Coding Statue Back amp Mais Deshbom The following reports are available 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 SIRS Report A more detailed list of all the babies born within the hospital for a specified time period N B The initial outcome field must be set for baby to appear in this report 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 Date of birth Date of admission Internal transfer date Date of discharge o External transfer date Patient L
19. d letter containing information for the Health Visitor e 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 Registration of Birth A pre populated Registration of Birth form Notification of Birth A pre populated Notification of Birth form EC58 A pre populated EC58 form which is under development Newborn Hearing Screening Form A blank screening form with the patient information pre populated e Pre populated Newborn Hearing Screening form this is prepopulated with GP and Mother details Section 14 System and Password Administration To access the Admin screen click on Admin from the main dashboard This screen allows you access to the following functions User administration SBR User Manuals and Quick Guides Automated imports Duplicate Records Record movement Tools User Administration Your view of this section will vary depending on the type of user you are Coding User This is where you can change your password and contact details SBR User Manuals and Quick Guides Click the link to open a new browser window and view the up to date SBR User Documentation This lists all the current manuals and guides which can be downloaded Automated Imports If you
20. der It is recommended that you use the built in search facility to enter the address and postcode Address Finder Web Page Dialog Address Finder street NB Do not use numbers in the Street name Town village Region County Postcode EH12 HEB Search Results 13 3 south Gyle Crescent Edinburgh Midlothian EH12 SEB 15 7 South Gyle Crescent Edinburgh Midlothian EH1 2 9EB 16 6 South Gyle Crescent Edinburgh Midlothian EHT12 9EB 17 South Gyle Crescent Edinburgh Midlothian EH12 3EB 174 South Gyle Crescent Edinburgh Midlothian EHT12 9EB select Find e Click on to the left of the address field e Search on either the postcode or part of the address Click on search Highlight click on the relevant address from the list presented Click select The 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 Do not enter a house name or number in the address search When searching on a postcode you should 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 Appendix D Glo
21. ease 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 analysis you require or you just need help getting the data out of the Excel spreadsheets then contact the SBR Team via the Atos Helpdesk Section 17 Contact The SBR helpdesk is maintained by Atos Origin and is available 24 7 You can contact them in a number of ways Feedback 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 Section 18 Logging Out Always click on pb
22. ens 9 ACCESS OP AUNT RECON E cuidarte 9 o seeiis ea ee ae se E E EE EEEE tux MM EEA i 10 Bo A E POS Un m 10 A A 10 Place of Birth Home Births Born Before Arrival amp Born Outwith Scotland 10 HO So MU E E o e OT DOTT TET 10 Recording Stillbirths and Neonatal death oooccccnnccccccconnncnnnononononanncnnnnononononnnennnnnonononanennnns 11 e aninion RE RN PUR 11 wie As e Big NITET RR T 12 Transtering a uii NER M 12 TADS TOG artis dutem TE E r 13 FAS AC IMISSIONS 21554 sac dacsatcesassdtcedandewodeattd saguchenborenes dsaddendeesidenbtd sacs obossainads ened dcndeesdecbsesags obeabeesessitesdanssi 13 EMU DPP ORT E E PES PRE REO A 14 See cbe ei arto 15 BIZ SCO I UNE 16 Section 12 Submitting and Retracting a Record ccccoooccnccccccnncconcnncoconcnnononcnnononnnnnnnoncnnononnnnononnnnnnnos 17 OBI 19 PIIBEHOOlls e een ee meme nme a 18 Section 14 System and Password Administration occccococcnncconcnnccconnnnonononnnnonnnnnononnnnnnoncnnnnonnnnnnnos 19 User PAINS AON METER 19 SBR User Manuals and Quick Guides cccccccocccccnnncccccconoccnnnnnnnnononononnnnnononononnnnnnnnnnnnnonannnnnnnnnnns 19 Automated TIMP ONS uuosic ice ntte tis dehet Qu testi PUO dean eos 19 a zeo au o uM 19 SCHON ei FRC
23. er have access to it If you have transferred a record and have forgotten to add something please contact the designated SBR user at the receiving site If you have transferred to the wrong hospital please contact the SBR Team who can un do the transfer for you If 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 If a baby has been transferred to you you must admit the baby on the Episode screen before it can be discharged A list of records that have been transferred from your hospital can be viewed on the Admin page under Record Movement 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 above detailing how to add an episode When a baby is re admitted to a different hospital after being discharged home from your hospital the baby record should be SENT and not TRANSFERRED to the admitting hospital to allow the episode information to be added Birth Screen Details on the birth can be entered and edited on the Birth screen Information here includes estimated gestation feeding on discharge and congenital anomalies Information Points 9 are provided beside various data fields to give information and guidance Simpson Bart Baty Codes 13 10 2011 Special Neonatal Care wese st sees Firs tan 25 N Est D
24. ername entered so that you will not have to enter it again when logging back in The Training System Please contact your local administrator or the SBR Team to confirm the username for your hospital Your training system password is training 1 PLEASE NOTE The training system does not reside on a secure website therefore please DO NOT enter any CONFIDENTIAL DATA The Live System To access the live SBR you will require a unique username You can obtain this from your local SBR Administrator or the SBR Team see Section 17 Contact Username vom Mew Password Cunha Hew Password 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 for advice Section 3 The Coding 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 lt also provides access to additional functions
25. f 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 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 It is 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 If the 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 3 GP Practice feeder Web Page tralog NB This will search on all GP Practices in the UK but will only return GMC Numbers for GPs practising GP Practice er in Scott nd GP Sumame lone GP Foreneene Address Cline thes feld te search os ad rezs detaia Postcode E H Seach Cheer Close Search Results 71516 3303995 Jones Co n 24 Gracemount Dive Edinburgh EHIS BAN 0131 64 2
26. ided 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 Recording 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 Episode Screen Data recorded here is for baby activity only Admission when a baby is admitted or re admitted to any ward within a hospital that provides any neonatal care this includes normal care 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 Discharge when a baby is discharged from inpatient care to the community transferred to specialist non neonatal care e g cardiology or transferred to a hospital out with Scotland Tree Willow 01 09 2012 Admission Internal Transfers CODING Date Lae today 12 09 2012 12700
27. initions I 10 adio Date This le ICD 10 ending showing all Ihe sodas vied for your hospital JU 5 84 Ceding Date This la OPCS seding showing all Ihe sedet uted for your heepital Definitions Uulada Mistery Dale is i Ine Eplsnde History delalla showing all episode event for your howital Back to Main Dashboard Data entered into the SBR can be downloaded then printed out or analysed locally These SBR data extracts and reports contain up to the minute information that has been entered 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 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 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 e Clinical Maternity Data All maternity data extracts based on a particular year for the current hospital e Clinical Ne
28. ioned 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 eet see er j pem Using National Search to locate a record not at your site National Search e Click on from the main dashboard Search using Baby Mother CHI number or SBR Indicator 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 SBR_Ind Mother CMI lt EZA Name ypb CHI Dea VER ind COM Num May DOG too te Lacaman Dota Crowd Section 5 Adding a New Record Before adding a new record it is advisable to search the database to ensure a record does not already exist see above To add a new record for the Baby e Click on Me from the main dashboard e Complete all the mandatory fields these are marked with R Click on Submit
29. is on the NHSNet which is the NHS private version of the Internet All interactions are password protected and the system now has a full audit trail We are planning further work 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 Universal Newborn Hearing Screening UNHS system which can be used independently from SBR however the two systems share the same unique SBH Indicator You may therefore be asked to transfer send records to other hospitals in other NHS Boards SBR Clinical Manual Version 6 8 February 2014 Page 1 Section 2 Log In There are two Scottish Birth Record SBR systems in operation Live and Training To access these systems e Double click on the relevant icon Train SBR or Live 3BR see Appendix B Setting Up Icons on Your Desktop e Enter a username and password e Click on Login button Username Password Remember me Clear To exit click here for press ALT F4 NB If you tick the remember me box the system will automatically remember the last us
30. ist reports on patients by either dates of birth gestation birth weight ICD or OPCS codes Annual Report shows full birth details including gestation birthweight feed on discharge discharge type multiples top 10 diagnosis 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 and percentage of total by selected year ALOS average length of stay 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 General Anaesthetic Epidural Anaesthetic Local Anaesthetic Spinal Anaesthetic Blood Loss Placenta Delivery Tears Episiotomy Type of Delivery Birth Weight Provides an analysis of the birth weights for the current hospital with a national comparison O O O Baby Sex Provides an analysis of the baby genders for the current hospital with a national comparison 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 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 Section 16 Export Data Clicking on teh nto from the main dashboard allows information to be taken from the SBR and printed out or ana
31. ke a minute or two depending on the amount of TEMP files Once it is completed click OK LUI er Tace Ert 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 Right clicking on amp xi 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 SAD NIS Iw c ocreen resolution to be set at 1024 x 768 To change you
32. king 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 Section 17 Contact Finding A Record Locally At Your Hospital The search facility can be found on the top of the dashboard a Forename alt HPI DoB EDD SBR Ind AAA A E A HN Doby Surrena J HA Orange Clear Mum C Baby Both amp EDD BabyDOB Mum pos C _Clear 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 The SBR Indicator is a unique system identifier for each SBR record It can be found below the surname on the dashboard Forename Baby mum Gaby DOB bof bern Wospit Patera IU CI 5 Racorts m tela Page 1 of Baby 14 08 2008 not entered E Dx J Baby 14 08 2008 not entered UD 5x UE ausm e Enter the data you are searching on i e surname DOB CHI
33. l 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 The Print Room gt GPR Aspon Regi wen of Em 7 T IR E Wt tre Meeborn Moe std eati Mier of Kurt vt De erate Feror Pw e Y APD ARE MEAT he a Loa ds tla er wie zum Za ca E om TN D x n d iad M xm AA LA 21 a T 7 r tre Sate E A z Pe s oye pate Oriihs ge etter Me ban e Ing icreensny Farma A v sir e ez AA uri ac att yt rt Thee u Po n es 9v gt FAri pet u y L EA EBAJOLpA e e 37 127 L The print room allows you to print reports and letters relating to a particular record from the SBR system To print the document Go to File Select Print The following reports can be generated from The Print Room e GPR Report An application form to register with a GP e 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 e Neonatal Discharge Letter A pre populated discharge letter for babies who were admitted for further neonatal care e Handover to Heath Visitor Letter A pre populate
34. l correspond to the gender of the baby Blue Boy Pink Girl 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 In order to obtain a CHI number the record you are sending must have a baby surname baby forename default Baby is valid valid postcode it must include a space sex baby date of birth and first line of address It is important that if you are registering multiple births where the baby has no forename and the default Baby is being used please use Baby l Baby Il Baby lll etc as the validation will not accept numeric characters E http tesk scottishbirthrecord scot nhs uk CHI Microsoft Internet Explorer POSSIBLE DUPLICATE FOUND Baby ii Egg If vau AGREE that the details retrieved from CHI are for the same patient please select KEEP EXISTING CHF to impor the existing CHI number into the SBR recard Ifvou are sure that this 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 TWIN or if you need to re allacate a CHI number If vau are MOT SURE how to proceed please select CANCEL and ask for help From SBR From CHI 1604105003 Keep Existing CHI Allocate New CHI Forename Baby li Baby Surname Egg Egg Date of Birth 16 04 2010 16 04 2010 Sex Female Female Address THE HOUSE THE H Post Code FH 12
35. lysed in a local system 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 directly on your PC Ses useful Tips for displaying data 2012 Go Ciinioa Metenity Date Tila la the Clinlos Maternity Dele Extract of ine Saalih Birth Record Dale By ras law Lennon Near t fa linics Neonatal Data This is tha Clinical haonatal Date Extract of ine Soottien Birth Record Date By res 2012 T Go lew Dalinilisni Baby Meeriial of Plah Dala This i the Baby Hosoltal of Birth Date Extract of the Goottien Birth Record Data Dos tomi tl Go Walaled Racuni hen yeu delete a SNA Massid Il it fel physcially deleled hom ihe delabcate Lis Only maed sr deleted B jaw 2012 Go law Letiniiions Booted bul ool val Delivered Thiele a extract of SBR Records for when the Mother hes been booked On Ihe yitam Out the baby hai ot yel been delivered View Dalinitiens n Ped n mis m sodino Date This le ma main Coding Dela By Yeu evils heo Go law Coding Dele Dal
36. o Enter any comments relating to the sending of the record e Click on AS E Send this Record Web Page Dialog Surname Barlow Forename Baby Date af Birth 14 07 2006 Baby HPI LZ 3000 Ei Send Cancel If a record has been sent to you from another site you will see this icon on the main dashboard EE P If a record has been transferred to you from another site you will see this icon on the main dashboard Section 11 Entering Patient Information Access to Patient Records Once you have created found your patient click on the P Code button on the main dashboard next to the appropriate record to access it The following tabs will be displayed Baby Episode Birth Codes VLBW only when the baby s details have been entered meet the very low birth weight study criteria To access the tabs click on the appropriate header 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 section 17 Contact Baby Screen Demographics This screen enables you to edit any of the patient or demographic fields associated with a baby including his her name and GP practice Please note that the Mother s address and HPI on the right hand side of
37. ogramme Files or Plus or Internet Explorer look for the explore exe e e At end of address put space kspacehttps www scottishbirthrecord scot nhs uk note this has to be EXACT or it will not work e Click on Next Type in Live Scottish Birth Record Click on Finish Appendix C Data Entry Guidance Tips General 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 When you enter any information you must click on the button to save the data Don t worry if you forget and change screen A warning message will appear notifying you that data you have entered has not been saved Click OK to save or Cancel to close the screen without saving Information Points v appear throughout the system hover your mouse over them to view 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 Where possible data items shaded in blue should be completed These are required for the National reporting It is important to fill out all fields using correct grammar and spelling as the information recorded can be used within the discharge letters and other documents When creating a new record those fields which are accompanied A A by an asterisk are mandatory and must be completed before the AN Foreneme cannot be bank new record can be added to the SBR I
38. onatal Data All neonatal data extracts based on a particular year for the current hospital e Baby Hospital of Birth Data Total numbers of babies born at the current hospital within a selected date range and showing current record location e Deleted Records A list of all records that have been marked as deleted for the current hospital e Booked but not yet delivered all records with no baby date of birth recorded e Coding Data All coding data based on a particular year for the current hospital e CD10 Coding Data A dump of all the ICD10 codes assigned to each SBR for the current hospital e OPCSA Coding Data A dump of all the OPCS4 codes assigned to each SBR for the current hospital e Episode History Data A list of all episode events for the current hospital 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 Open up Windows Explorer go to Tools Folder Options 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 pl
39. ord had been moved to another site for postnatal information to be added 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 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 t
40. pleted 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 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 maternity 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 are being entered onto the SBR system The SBH 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
41. ppears saying Another member of staff in Once they have closed this that this record is locked for your Hospital has this record record you will be able to editing open access it yourself You are unable to access the Please report the fault to the Excel file in the Reports SBR Team at Information section Services asking you if you need help AutoComplete setting requisites in Appendix A completing the form The background colour on The Print settings for Internet Follow the steps in Appendix the forms in the Print Room Explorer are set to print A is being printed background Page cannot be found error The NHSNet is currently displays down or there is a fault with helpdesk the SBR You have forgotten your UJ 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 oystem 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 Internet Click on Explorer 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 ta
42. quired to amend prior to being able to obtain a CHI number 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 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 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
43. r a discharge transfer it has a different stay number A stay can be comprised of a number of transfers within the one hospital or between different hospitals To enter ICD10 codes 1 Select the stay you want to code by clicking on the drop drown box at the top right of the screen and selecting the appropriate number 2 Enter the main condition code and any other conditions if required into the appropriate fields 3 To enter multiple ICD10 codes put a between codes for the Other Conditions There is no limit to the number of codes you may enter 4 Click on the update button at the bottom of the screen and the textual description then appears in the history box To enter the OPCS4 codes 1 Select the stay you want to code by clicking on the drop drown box at the top right of the screen and selecting the appropriate number Enter the operation code into the appropriate fields Add the consultant responsible Add the date of main operation Click on the update button Qs Go Tw You can enter 2 or more OPCSA codes that are the same as long as the dates of the operations procedures are different The functionality to remove OPCS4 and ICD10 codes as well as a free text box at the bottom of the screen for comments is also provided Please note that only codes relating to the baby should be entered on this screen and not any codes relating to the Mother A Coding Output document is available from the Printroom if required VLBW
44. r screen resolution Click on Start at the bottom of your screen 1 2 Select Settings 3 Click on Control Panel 4 Double click on Display 5 Goto the Settings tab 6 Under Screen area click on and drag the slider to 1024 x 768 7 Click Apply Notes e A higher 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 Appendix B Setting Up Icons on Your Desktop Settina up a Training SBR logo on your deskto e Firstly ensure that your PC is linked to the NHSNet e Right click on the desktop e Select New e Select Shortcut e 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 e Double click or OK e Atend of address put space kspacehitp test scottishbirthrecord scot nhs uk e Click on Next e Type in Training Scottish Birth Record e 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 Select New Select Shortcut Create shortcut dialogue box appears browse to where you have your Internet explorer usually on their local disk C D Pr
45. ssary Discharge when a baby is discharged from inpatient 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 ICU7 e Needing 1 1 nursing care by 405 equivalent Intubated 24 hours post extubation NCPAP 4 5 days old for any part of the day NCPAP 4 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 AN
46. t 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 Transter e To complete 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 instance is the date the baby leaves Scottish hospital care Tips for Transferring 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 At present once a record has been transferred you cannot access it unless the record is transferred or sent back to you Ensure that you complete the record with as much information as possible BEFORE you transfer the record as once you have transferred sent it you will no long
47. this screen cannot be edited here When a baby is transferred to you from another hospital please overwrite the Hospital Patient Identifier with your own X anmenm Pina rare O0 Sexuewwm cf O Time of Gath 117 36 h omm 24 v prose ot em Homebirth plan NK S songas stm A LJ 39 Find E 1 env omo Weis Scan oun A OH F reber ataca tip CHIEXME Intertece irio coto Potan santa 0 EENNNNN T fam o eo Pwcee ru2xB omiensa O a maiat 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 This field along with the sex of the baby will be locked and will appear in grey once the CHI has been allocated Place of Birth Home Births Born Before Arrival amp Born Outwith Scotland 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 prov
48. y have been added by the clinical users Section 8 Saving a Record Before you move screens within the SBR or exit the record click on to save the information you have entered If you try to change screens or exit the record without updating first a message box will appear notifying you the data you entered has not been saved Click OK to save or Cancel to close the record without saving Section 9 Deleting a 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 lf 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 amp beside the appropriate record to bring up a list of administrators contact details or please refer to section 17 Contact for the SBR team Section 10 Sending a record 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 Coders may need to use this facility to send or retrieve a record for coding if for example the rec
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