STB Medicine Collection Guide: Difference between revisions

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This article contains information specific to STB Medicine, see the [[Medicine Curriculum]] for general information, and [[STB Collection Guide]] for St Boniface specific information.  
This article contains information specific to STB Medicine.
 
*See '''[[STB General Collection Guide]]''' for general STB information such as: links to EPR, Mail room, medical records. Information also in regards to obtaining hand sanitizer, wipes, printer paper for collection offices.
*See '''[[Medicine Curriculum]]''' for general information,
* Jan 17, 2025 the total number of medicine beds is 121, this will increase by 5 in the coming months.
''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles. ''
''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles. ''


See also:
* The Respiratory service admits patients to B5 under the SBGH Internal Med / Respiratory service. The number of beds that are occupied by these patients can fluctuate from day to day and as such so will the census for medicine patients that are admitted to B5. We do NOT collect data on the patients admitted under the respiratory service.
* [[STB 5B Collection Guide]]
*When a patient is discharged to B5 under the respiratory service the [[Dispo field]] should be STB_Ward, similarly if you admit a patient from B5 that was under the respiratory service the [[Admit from]] should be STB_ward
* [[STB E6 Collection Guide]]
*We do collect nephrology patients that are admitted to B5.
== Location of information ==
We use EPR for all Admit/Transfer/Discharge times. ENagy
 


==6AS Transitional Care Unit collection guide ==
Generally speaking patients that have been admitted to any of the active medicine units, E5 (A service), 5B (C service) and E6 (B medicine) are transferred there once they have been deemed medically stable and are waiting for placement or geri rehab, stroke rehab etc.


Medicine would like to track these patients and as such  the following situations may arise. 


On the very rare occasion patients are admitted directly from the ER or elsewhere to 6AS:
See also:
* [[STB B5]]
* [[STB_E6_B]]
* [[STB E5]]
* [[STB EMIP]]
* [[STB A6ME]]
== STB Swing Beds ==
*STB Swing Bed entries are "bed" records within a "unit" in EPR/Cognos. They are not beds or locations but conceptual service location and time entries used for patient moves. This data causes a patient record to show up in Cognos/CUS as having arrived on a unit even when the pt has not actually arrived, and it isn't visible in our listings whether the record is for a swing or real bed.
*Since any CUS entry at STB may be either a swing bed or a real bed, service locations and times need review.
For Medicine, the swing bed entries will often be obvious as the unit stays will be a matter of minutes
If a CUS entry is for a swing bed, manually exclude using the "exclude" button


1. If they are admitted under family medicine, we do not admit them, in other words ignore them completely
== Location of information ==
2. If they are admitted under one of the teaching services, then the collector who collects that data will enter them on their laptop.  Ie. If admitted under A Service it will go on the E5 laptop, if B service then it would go on the 6E/5B laptop etc.  As for the overstay, the allied health and nursing staff do NOT fill out these forms, so the overstay would be entered as “data missing” and the color would still be generated.  If they are a red- there is no binder for allied health staff, so nothing more needs to be done
 
When a patient is transferred to 6AS from one of the wards and remains under the teaching service, then that patient should be followed until either time of discharge/transfer or until they are transferred to the family medicine service. (As long as they are admitted under one of the teaching services, we should be following them)
 
When/if a patient is transferred to 6AS from a teaching service ward directly to 6AS but under a new teaching service then the collector responsible for that service will enter them as a new profile.  Ie. If a patient is transferred from A service (E5) to 6AS but under C service, a new profile will be created on the 6E/5B laptop, the location should be 5B, and the patient should be considered a transfer from 5E to 5B 
 
When a patient is admitted/transferred from 6AS to one of the teaching wards:
 
1. If they have remained under one of the teaching services and are transferred back to the same teaching service ward this should be one continuous admission and no new profile is needed
2. If they were under family medicine, then a new profile should be created under whichever teaching service they have been accepted to
3. If they were under a teaching service on 6AS and are transferred to a different teaching service then a new profile should be created by the collector who collects for that service. Ie. If a patient is admitted under C service on 6AS and is transferred to 5E, then a new profile should be created for 5E and the patient should be considered transferred from the 6E/5B laptop
 
==Medicine Overflow Patients==
 
On occasion medicine patients are transferred to off service wards, but are still admitted under the internal medicine service.  ie. patient transferred from E6 to 7AS (surgical ward) but still admitted under internal medicine.  The attending may be different than the admitting service but it is still an internal medicine attending.  Please continue to follow these patients (no new profile is required) until they are discharged or transferred to an off service ward.  Please make a note in the "notes" section of the profile.  There is no need to fill out any variables on the registration tab. 


* [[Cognos2]] is used for collection of Admit/Transfer/Discharge (A/D/T) dates/times
**See [[Using Cognos2 to keep track of patients]] for further information


* The [[STB Electronic Patient Record]] is used to review documentation as needed and to complete collection for patient discharges


== work load splitting ==
[[Serial_number#STB_5B:_Serial_number_share_plan]]
{{discussion}} This is no longer split, right? Ttenbergen 16:28, 2016 March 14 (CDT)


== vacation coverage ==
See [[Visit Admit DtTm field]] for further information
For those collectors who are doing vacation relief for the regular collectors who are away, catch up from time off can be expedited for the returning collector if the following things are prioritized.
#do opp and color generation. ADL's are a component of the opp and can be found on the [[STB Electronic Patient Record]]. They are in "initial assessment" form under the documents tab. Everything needed for minimal data will be included if the opp is done.
#medicine apache score. The SBGH ER unit is online with their vital signs and neuro assessment. This means that the vital signs and gcs required for the apache score can now be found under the flow sheets tab. To access neuro check, click on flow sheets, then care and assessment, then neuro. The only exception to this is for patients admitted to the unit from MICU. MICU does not use epr (electronic patient record) for vital signs, and hence apache for these patients still need to be obtained from the paper flow sheet in the chart.


The only things that need to be taken from the paper chart are the dpst info. If the opp is kept current and up to date then charts would not have to be pulled from medical records by the person returning from vacation. This would help tremendously in catching up from time off for the returning collector.[[User:DPageNewton|DPageNewton]] 14:40, 2013 February 20 (EST)
== Boarding Loc ==
[[Category:Vacation]]
see [[STB_Medicine_workload_splitting#Boarding_Locs]]


*Vacation relief for Elaine is covering E6 and B5 medicine.  For Debbie, coverage is for E5.
== STB Medicine workload splitting ==


== [[Overstay Predictor Project Collection Instructions|Overstay Project]] ==
=== STB Medical Records requests ===
SBGH has now gone to paperless charting or [[STB Electronic Patient Record]]. This means that we can now review almost the entire chart on the computer. The exceptions to this are:
* Not needed for STB Medicine Program collection
#the DPST Form. The information found on this form is one part of the information we need for the overstay predictor project (opp).
#the medicine apache score. The patients admitted to the wards from MICU, are the only patients that you would need to look on the paper chart. Patients admitted/transferred from either ER or other wards have the apache elements online in the epr. Look in the MICU flow sheet for the apache elements for those patients coming from MICU.


== Lab results ==  
== APACHE tab ==
Lab results are now entirely online in the epr.
Use EPR vital signs to collect the Medicine items for Apache


== Office and staff ==
== Office and staff ==
see [[:Category:St Boniface Hospital Office (Medicine)]]
see [[:Category:St Boniface Hospital Office (Medicine)]]


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


[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:Site Specific Collection Guide]]
[[Category:Site Specific Collection Guide]]
[[Category: Data Collection Guide]]
[[Category:Data Collection Guide]]
[[Category:Overflow]]
[[Category:Overflow]]

Latest revision as of 11:59, 30 July 2025

This article contains information specific to STB Medicine.

  • See STB General Collection Guide for general STB information such as: links to EPR, Mail room, medical records. Information also in regards to obtaining hand sanitizer, wipes, printer paper for collection offices.
  • See Medicine Curriculum for general information,
  • Jan 17, 2025 the total number of medicine beds is 121, this will increase by 5 in the coming months.

Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles.

  • The Respiratory service admits patients to B5 under the SBGH Internal Med / Respiratory service. The number of beds that are occupied by these patients can fluctuate from day to day and as such so will the census for medicine patients that are admitted to B5. We do NOT collect data on the patients admitted under the respiratory service.
  • When a patient is discharged to B5 under the respiratory service the Dispo field should be STB_Ward, similarly if you admit a patient from B5 that was under the respiratory service the Admit from should be STB_ward
  • We do collect nephrology patients that are admitted to B5.


See also:

STB Swing Beds

  • STB Swing Bed entries are "bed" records within a "unit" in EPR/Cognos. They are not beds or locations but conceptual service location and time entries used for patient moves. This data causes a patient record to show up in Cognos/CUS as having arrived on a unit even when the pt has not actually arrived, and it isn't visible in our listings whether the record is for a swing or real bed.
  • Since any CUS entry at STB may be either a swing bed or a real bed, service locations and times need review.

For Medicine, the swing bed entries will often be obvious as the unit stays will be a matter of minutes If a CUS entry is for a swing bed, manually exclude using the "exclude" button

Location of information


See Visit Admit DtTm field for further information

Boarding Loc

see STB_Medicine_workload_splitting#Boarding_Locs

STB Medicine workload splitting

STB Medical Records requests

  • Not needed for STB Medicine Program collection

APACHE tab

Use EPR vital signs to collect the Medicine items for Apache

Office and staff

see Category:St Boniface Hospital Office (Medicine)

Related articles

Related articles:
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