STB Electronic Patient Record: Difference between revisions

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This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]].

~~== [[Arrive DtTm]] ==~~

~~=== ICU ===~~

*In ICU we were told to use the first vital signs on the nurses' flow sheet for admit date and time. ICU nurses always do vitals immediately upon arrival of the patient to the unit. This can differ from the EPR arrival time to the unit as that time relies on ward clerks entry time of arrival. I also find that the discharge or death times can differ significantly for the same reason. It would be inaccurate to use only EPR times without checking the flow sheets. It is very important to get the right time for ICU because our "APACHE" score relies upon the worst vitals and labs within the first 24 hours. Even a few minutes can make a difference on the apache value.

~~=== Medicine ===~~

*For medicine, we do use the EPR time.

** Vital signs don't get done right away so are no better data than the EPR.

~~{{Discuss |~~

* "...Also, the "APACHE" score for medicine is not dependent upon the first 24 hours of vital signs and labs so exact accuracy here is less important. --[[User:LKolesar|LKolesar]] 06:44, 2019 October 24 (CDT)"

** We don't do an apache score for medicine at all, so I am not sure what you mean here. AFAIK the instructions how to collect e.g. [[WBC]] are the same for medicine and ICU, no? In any case, I think it's separate from the purpose of this page, how EPR is used at STB. If you agree, can you please take out this whole Discussion? Ttenbergen 11:31, 2019 October 30 (CDT)

}}

== Implementation Status ==

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* laboratory

* 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

* physicians OR notes

* 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 ===

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=== Data still recorded only outside of EPR / on paper ===

* continuous medication infusions

* vital signs for apache from icu flowsheets,

* amount of blood products delivered from the blood transfusion record sheet

* TEE reports for patients having OHS

* echo reports

* anesthesia record

* blood product sheets (orders for blood should be on EPR) Sometimes the orders and other sources of information (flow sheets, blood product sheets) differ.

* nurses flow sheets

* intake and output sheets

* CRRT sheets

* GCS sheets

* GCS sheets; neuro assessments are accessible via EPR flowsheets

== Related articles ==

@@ 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]].
-== [[Arrive DtTm]] ==
-=== ICU ===
-*In ICU we were told to use the first vital signs on the nurses' flow sheet for admit date and time. ICU nurses always do vitals immediately upon arrival of the patient to the unit.  This can differ from the EPR arrival time to the unit as that time relies on ward clerks entry time of arrival.  I also find that the discharge or death times can differ significantly for the same reason. It would be inaccurate to use only EPR times without checking the flow sheets. It is very important to get the right time for ICU because our "APACHE" score relies upon the worst vitals and labs within the first 24 hours. Even a few minutes can make a difference on the apache value.
-=== Medicine ===
-*For medicine, we do use the EPR time.
-** Vital signs don't get done right away so are no better data than the EPR.
-{{Discuss |
-* "...Also, the "APACHE" score for medicine is not dependent upon the first 24 hours of vital signs and labs so exact accuracy here is less important. --[[User:LKolesar|LKolesar]] 06:44, 2019 October 24 (CDT)"
-** We don't do an apache score for medicine at all, so I am not sure what you mean here. AFAIK the instructions how to collect e.g. [[WBC]] are the same for medicine and ICU, no? In any case, I think it's separate from the purpose of this page, how EPR is used at STB. If you agree, can you please take out this whole Discussion? Ttenbergen 11:31, 2019 October 30 (CDT)
-}}
 == Implementation Status ==
@@ Line 23: / Line 10: @@
 * laboratory
 * 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
 * physicians OR notes
 * 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 ===
@@ Line 33: / Line 23: @@
 === Data still recorded only outside of EPR / on paper ===
-* continuous medication infusions
 * vital signs for apache from icu flowsheets,
 * amount of blood products delivered from the blood transfusion record sheet
-* TEE reports for patients having OHS
-* echo reports
 * anesthesia record
 * blood product sheets (orders for blood should be on EPR)  Sometimes the orders and other sources of information (flow sheets, blood product sheets) differ.
-* nurses flow sheets
 * intake and output sheets
 * CRRT sheets
-* GCS sheets
+* GCS sheets; neuro assessments are accessible via EPR flowsheets
 == Related articles ==