STB Electronic Patient Record: Difference between revisions
Ttenbergen (talk | contribs) |
No edit summary |
||
| (8 intermediate revisions by 3 users not shown) | |||
| Line 1: | Line 1: | ||
This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]]. | This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]]. | ||
== Implementation Status == | == Implementation Status == | ||
| Line 14: | Line 10: | ||
* laboratory | * laboratory | ||
* pharmacy data (MAR) | * pharmacy data (MAR) | ||
* integrated progress notes | * integrated progress notes, EPR flowsheets are used to record any information that does not occur hourly e.g. head to toe assessments, lines, events, neuro assessment | ||
* nurses operative report | * nurses operative report | ||
* physicians OR notes | * physicians OR notes | ||
* Central line insertions | * Central line insertions | ||
* diagnostic imaging, including echocardiograms | |||
* Cardiac Catheterization reports; access results via link to the right of the document | |||
* Results for intraop echo for the [[Project ABO TEE]] | |||
=== Data documented in paper and EPR === | === Data documented in paper and EPR === | ||
| Line 24: | Line 23: | ||
=== Data still recorded only outside of EPR / on paper === | === Data still recorded only outside of EPR / on paper === | ||
* vital signs for apache from icu flowsheets, | * vital signs for apache from icu flowsheets, | ||
* amount of blood products delivered from the blood transfusion record sheet | * amount of blood products delivered from the blood transfusion record sheet | ||
* anesthesia record | * anesthesia record | ||
* blood product sheets | * blood product sheets (orders for blood should be on EPR) Sometimes the orders and other sources of information (flow sheets, blood product sheets) differ. | ||
* intake and output sheets | * intake and output sheets | ||
* CRRT sheets | * CRRT sheets | ||
* GCS sheets | * GCS sheets; neuro assessments are accessible via EPR flowsheets | ||
== Related articles == | == Related articles == | ||