Notes field: Difference between revisions
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===Guidelines=== | ===Guidelines=== | ||
*Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others. | *Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others. | ||
=== Patients being sent === | === Patients being sent === | ||
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* Extreme data that was confirmed as correct: | * Extreme data that was confirmed as correct: | ||
** extreme physiological APACHE values, eg Sys BP of 50 valid , see [[APACHE_Scoring_table]] and [[APACHE_physiological_variable_collection#Exceptionally_high_or_low_values]] | ** extreme physiological APACHE values, eg Sys BP of 50 valid , see [[APACHE_Scoring_table]] and [[APACHE_physiological_variable_collection#Exceptionally_high_or_low_values]] | ||
** | ** to verify imaging counts ie. 2 day LOS and 12 CXR's done, you may want to write a short note that the imaging counts are correct or have been double checked | ||
** Some are using this for VAP adjudication criteria, these notes can stay in case there are future questions re. VAP | |||
*Upon review of the Notes field, and prior to sending, please delete any data that would not be used to clarify extreme data or outliers. The main office will use this to clarify extreme data, so deleting excess data in this field will help streamline this process for the main office. | |||
==== Up-to where/when collection is complete ==== | ==== Up-to where/when collection is complete ==== | ||
* STB - where we have left off reading in the EPR notes by entering the date/time last read | * STB - where we have left off reading in the EPR notes by entering the date/time last read | ||
*HSC- where we have left off checking orders, pharm, counting EPR labs, reading notes by entering the date/time last read. | |||
==== Diagnoses or other data that needs to be reviewed or checked ==== | ==== Diagnoses or other data that needs to be reviewed or checked ==== | ||
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==== Supplemental data ==== | ==== Supplemental data ==== | ||
* to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them. | * to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them. | ||
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| always= We tried to standardize field into a kind of form, but collection practice is too non-standard to come up with a format that worked. | | always= We tried to standardize field into a kind of form, but collection practice is too non-standard to come up with a format that worked. | ||
| full= | | full= | ||
Just being curious if the notes field is a free space for '''optional''' additional info....what specific problems did this cause? | |||
*I actually prefer a blank notes field. The premise was good but turns out to not be all that helpful.--[[User:CMarks|CMarks]] 11:53, 2018 December 6 (CST) | *I actually prefer a blank notes field. The premise was good but turns out to not be all that helpful.--[[User:CMarks|CMarks]] 11:53, 2018 December 6 (CST) | ||
Latest revision as of 12:05, 2024 October 25
| Data Element (edit) | |
| Field Name: | Notes |
| CCMDB Label: | Notes |
| CCMDB tab: | Top Row |
| Table: | L_Log table |
| Data type: | memo |
| Length: | not stated |
| Program: | Med and CC |
| Created/Raw: | Raw |
| Start Date: | 1988-07-11 |
| End Date: | 2300-01-01 |
| Sort Index: | 9 |
Used by data collectors to keep notes during collection.
The notes field expands to a bigger form when you double-click on it.
Usage of the notes field
The notes field was set up to be a free-for-all where collectors can store any info they want. This resulted in non-standardized collection practices which result in problems during vacation coverage or on shared wards.
Guidelines
- Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others.
Patients being sent
- For patients you are ready to send, make sure you note explanations for data values that you think might cause call-backs from the Data Processor or Statistician. For example:
- Extreme data that was confirmed as correct:
- extreme physiological APACHE values, eg Sys BP of 50 valid , see APACHE_Scoring_table and APACHE_physiological_variable_collection#Exceptionally_high_or_low_values
- to verify imaging counts ie. 2 day LOS and 12 CXR's done, you may want to write a short note that the imaging counts are correct or have been double checked
- Some are using this for VAP adjudication criteria, these notes can stay in case there are future questions re. VAP
- Upon review of the Notes field, and prior to sending, please delete any data that would not be used to clarify extreme data or outliers. The main office will use this to clarify extreme data, so deleting excess data in this field will help streamline this process for the main office.
Up-to where/when collection is complete
- STB - where we have left off reading in the EPR notes by entering the date/time last read
- HSC- where we have left off checking orders, pharm, counting EPR labs, reading notes by entering the date/time last read.
Diagnoses or other data that needs to be reviewed or checked
Can be used to document suspected diagnoses (which would not be coded in ICD10 even for incomplete records, as per ICD10 collection#"Suspected" Diagnoses.
Supplemental data
- to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
- be aware that 99% diagnosis data analysis in the main office will not look at the notes field, as usually there are just filters or counts on the ICD10 dx entries.
- to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.
- to define what exactly needs to be entered, when a profile is only partially completed.
Automatic population of notes field for newly entered patients
| We tried to standardize field into a kind of form, but collection practice is too non-standard to come up with a format that worked. |
|
Just being curious if the notes field is a free space for optional additional info....what specific problems did this cause?
Recently a format was implemented and placed into the notes field. We would like to know if this format is helpful and if you use it. Please indicate here if you use it or not and any comments you would like to make regarding this:
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