Good Practice

NHS Digital advise that NHS staff should adopt the following good practice to determine the patient’s demographics for the trace. The questions included are best asked face to face with the patient. Their purpose is to try to determine the actual demographic details that are recorded on the PDS:

  • Ask for the patient’s full name.
  • Ask the patient how they spell their name as it may be different to conventional spelling.
  • Ask to check if they use a shortened version of their given name- i.e. "Chris" instead of "Christopher" or "Christine".
  • Confirm that their given name is their first name, for example "David Andrew Jones" may call himself Andy.
  • Check that you have the given name and family name the correct way round.
  • Care must be taken when tracing babies. Names may not be present (eg. Baby Johnson) or may have changed when the baby was formally registered with the Registrar of Births and Deaths.
  • Many patients from cultural groups only know the year of birth. Users should then use 1 January with that year as an estimate.
  • Some patients do not know their date of birth. Where this is the case, users should use the patient’s age to derive the year of birth and then use 01/01 of that year as the date.

Gender can have the following values:

  • Male
  • Female
  • Not Known (i.e. the user has never updated the field)
  • Not Specified (i.e. user has identified that fact is not known)

If you are tracing a patient record on the basis of telephone or written communication, it may be difficult to determine the gender of the patient. In a number of cases, gender may be derived from patients’ full first name. However, in the case of unfamiliar names, it is always advisable to check gender with the patient rather than making an assumption.

  • Tracing on postcode searches all current addresses stored in the NCRS. This includes the address that the patient informed the GP of when they last registered.
  • Ask for the patient’s postcode for where they live.
  • Check to ensure that the postcode provided is for their permanent address and not that of a temporary address.
  • Ask if the patient how long they have lived at this address. If it is a short time, then this may be the first time the NHS has been informed of the move. In this case, search on the previous address.
  • Postcodes should include a space between the two elements, e.g. SY3 2TT is valid; SY32TT is not valid.

At a minimum, the possible matches should also be checked for the following details:

  • Have the given names been transposed e.g. William John to John William?
  • Could the given name be spelt differently e.g. Phillip or Philip?
  • Has the sex been assumed based on given name e.g. Leslie, Frances, Hilary, Ashley etc?
  • Is the date of birth recorded in an American format e.g. 12/05/1989 was recorded instead of 05/12/1989? This displays as 12 May 1989 instead of 05 December 1989.
  • Has the date of birth been transposed, e.g. 12 May 1989 instead of 21 May 1989?