Lost/missing chart: Difference between revisions

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{{DiscussTask |
== Deferral period ==
Working on std instructions on what to do about lost charts. More to come.
*A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (same day number, 6 months later) after the patient has been discharged from the hospital or died in hospital.
}}
*Once that occurs, the record status will be updated to "Discontinued".
 
*Operationally, this will be done via ad hoc communication with the office (Pagasa).
== Additional info ==
*A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (180 days) after the patient has been discharged from the hospital or died in hospital.
*At that point the laptop record will be given the status of '''Discontinued'''.
*The mechanism for recognizing this situation, and changing the record status will be ad hoc, will work through Pagasa.


== Instructions for finishing off the profile ==
== Instructions for finishing off the profile ==
Line 14: Line 10:
* Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible
* Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible
** This includes any diagnostic imaging and procedure counts and results, lab results, etc
** This includes any diagnostic imaging and procedure counts and results, lab results, etc
* Where you can not get past a cross check because data is not available, explain that in the [[Notes field]]
* Where you can not get past a [[cross check]] because data is not available, explain that in the [[Notes field]]
{{Discuss |
* Regarding APACHE variables for these charts:
* what should be the instruction for APACHE - the usual "enter normal if not available" or should they enter extremes or 0s, or leave blank? What will not mess with Julie's processes?
**Usually we consider variables that are missing to be normal values.  But for these charts we cannot do so, so while you should code those APACHE variables for which there IS data, for those APACHE variables for which there is no data, enter the numeric code for "missing" i.e. the negative number -999
** I would rather have a missing APACHE Score when any of the APACHE elements are missing due to Lost or missing chart.  Entry of zero for numeric or blank for character on any of the elements results to blank APACHE Score  (but this refutes the guideline for APACHE Physiologic Not available).   Normal values result to Zero APACHE Score (when age pts is zero). }}
*** Entering this will, of course, trigger cross-checks, but that's OK since you won't be able to set the [[RecordStatus]] to "complete" anyway
{{Collapsable
* You probably won't be able to set the [[RecordStatus]] to "complete" since there will be data missing; even if you are able to, '''don't set the record to "complete"
| always= the following doesn't apply yet, waiting to confirm as of 2021-04-07
* When you have entered all available information, and when the [[#Deferral period]] has passed, contact Pagasa and tell her the profile is a missing/lost chart
| full= 
* Once Pagasa has confirmed that this is understood and set the [[RecordStatus]] to 'Discontinued", delete the chart using the [[♻️ button]]
* When you have entered all available information, and when the [[#Deferral period has passed]], contact Pagasa and tell her the profile is a missing/lost chart
* Once Pagasa has confirmed that this is understood, delete the chart using the [[♻️ button]]
}}


=== Instructions for Data Processor ===  
=== Instructions for Data Processor ===  
[[Category:Data Processing]]
[[Category:Data Processing]]
{{Discuss |
The Data Processor will manually set the [[RecordStatus]] for these to "Discontinued"; information on the lost chart status can be entered into the [[Notes]] field.
* Do we want a different [[RecordStatus]] for these? If not, should they be considered complete or incomplete?
 
** I suggest we enter a new one say,  '''LostChart''',  in the [[RecordStatus]] which  implies incomplete and  some data are missing. --[[User:JMojica|JMojica]] 13:34, 2021 April 7 (CDT)
A line is also added to [[L Problem table]] for each discontinued record:  
*** Would there be any problems with reporting queries including or excluding these in unintended ways? Could happen if any use a "not incomplete" or similar. I am pretty sure if we change this some CFE cross checks will show false positives for these, but those would be easily tweaked as we encounter them. Would there be false negatives, though? [[User:Ttenbergen|Ttenbergen]] 14:15, 2021 April 7 (CDT)
* D_ID
**** do you have a query about missing entry in any fields? I can't think of any query with false negative. --[[User:JMojica|JMojica]] 17:13, 2021 April 7 (CDT)}}
* Query - blank
* Notes - any known info about why discontinued, and what is available
 
=== Excluded from reporting ===
Discontinued charts are excluded from cross-checks, reporting and other data extracts. <!-- JALT 2022-08-04 -->


== Incomplete/lost profiles ==
== Log ==
{{Discuss |
As of 2022-03 all "lost chart" records have been set to [[RecordStatus]] "discontinued" and documented in [[L Problem table]].  
Julie says Pagasa keeps a list of records for which this applies. Can we keep it here instead? If there are good reasons not to, can we link from here?
* If we change the [[RecordStatus]] to '''LostChart''' for these there will be no need for lists, just a one-time update needed by Pagasa; I think that would be the best way to do this.  
}}
{{Collapsable
| always= click expand to see list
| full= 
* HSC_D5-36 
* HSC_D5-39 
* HSC_D4-3 
* HSC_SICb-1409 
* HSC_SICa-1887 
* STB_MICU-15213
}}


== Related articles ==  
== Related articles ==  
{{Related Articles}}
{{Related Articles}}


[[Category: Data Collection Guide]]
[[Category:Data Collection Guide]]

Latest revision as of 11:33, 30 July 2025

Deferral period

  • A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (same day number, 6 months later) after the patient has been discharged from the hospital or died in hospital.
  • Once that occurs, the record status will be updated to "Discontinued".
  • Operationally, this will be done via ad hoc communication with the office (Pagasa).

Instructions for finishing off the profile

An profile for a missing chart might trigger CCMDB.accdb Data Integrity Checks, so it can't be sent the normal way and the following process applies instead.

Instructions for Collectors

  • Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible
    • This includes any diagnostic imaging and procedure counts and results, lab results, etc
  • Where you can not get past a cross check because data is not available, explain that in the Notes field
  • Regarding APACHE variables for these charts:
    • Usually we consider variables that are missing to be normal values. But for these charts we cannot do so, so while you should code those APACHE variables for which there IS data, for those APACHE variables for which there is no data, enter the numeric code for "missing" i.e. the negative number -999
      • Entering this will, of course, trigger cross-checks, but that's OK since you won't be able to set the RecordStatus to "complete" anyway
  • You probably won't be able to set the RecordStatus to "complete" since there will be data missing; even if you are able to, don't set the record to "complete"
  • When you have entered all available information, and when the #Deferral period has passed, contact Pagasa and tell her the profile is a missing/lost chart
  • Once Pagasa has confirmed that this is understood and set the RecordStatus to 'Discontinued", delete the chart using the ♻️ button

Instructions for Data Processor

The Data Processor will manually set the RecordStatus for these to "Discontinued"; information on the lost chart status can be entered into the Notes field.

A line is also added to L Problem table for each discontinued record:

  • D_ID
  • Query - blank
  • Notes - any known info about why discontinued, and what is available

Excluded from reporting

Discontinued charts are excluded from cross-checks, reporting and other data extracts.

Log

As of 2022-03 all "lost chart" records have been set to RecordStatus "discontinued" and documented in L Problem table.

Related articles

Related articles:
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