It is critical that all patient care is accurately coded so that any SAS input to a patient's clinical pathway is recorded, whether or not this is a direct referral.
The NHS requires input of accurate data to reflect clinical activity and trusts now have a financial incentive to ensure that coding is accurate, comprehensive and timely.
Where a SAS doctor is undertaking autonomous practice, coding will help to strengthen the data collected. This is something that should be done with the support of the trust and department.
There are several ways to accurately record patient care and outcomes depending on the local IT system in use.
There is normally a way to record this element of a patient's care although sometimes this may require a simple tweak to the system by an IT professional.
The Health and Social Care Information Centre has confirmed that for local recording, organisations can record patient care under a SAS doctor using local codes. However, currently these will need to map back to national codes for reporting purposes.
As the NHS Data Dictionary language is yet to be updated, for the purposes of national reporting in England, it is the 'Consultant Code' that must be recorded and a SAS doctors name should be introduced as a consultant episode.
Guidance from the Academy of Medical Royal Colleges specifies that the term consultant also refers to certain senior doctors with appropriate competencies, to include those in Staff, Associate Specialist and Senior Specialty Doctor (SAS) grade posts.
When the sole responsibility for the patient is retained by the SAS doctor the 'Consultant Code' should be that of the SAS doctor, using their General Medical Council Reference Number.