STB Electronic Patient Record: Difference between revisions

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~~'''~~EPR~~''' -'''E'''lectronic''' P'''atient '''R'''ecord~~

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

*also referred to ~~as '''EHR''' - '''E'''lectronic '''H'''ealth ''' R'''ecord~~

~~Currently only~~ at ~~the ST Boniface Hospital~~

== Implementation Status ==

All sites are at different stages of EPR implementation. It is fully implemented at STB.

*~~What is EHR~~?- ~~[http://www.manitoba~~-~~ehealth.ca/news.html EHR News]~~

=== Data only documented in EPR ===

**~~Phase 1 of~~ EPR ~~which includes patient registration~~ information, ~~labs~~, ~~some patient information~~, ~~billing information started April 12~~, ~~2007~~

* data listed at [[EPR#Data in EPR]]

**~~Phase 2A includes order entry, order management and medication worksheet~~ for ~~nurse documentation (MAR) was implemented between December 2008 to February 2009.~~

* Physician orders

* laboratory

* pharmacy data (MAR)

* 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 ===

* endoscopy has a paper version and an EPR version.

* heart cath has both paper and EPR versions of the report.

==~~eHealth-System Access Form~~==

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

* vital signs for apache from icu flowsheets,

~~[http://intranet.sbgh.mb.ca/Forms/files/SBGHSystemAccessForm.doc STB-eHealth application form]~~

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

~~--[[User:TOstryzniuk|TOstryzniuk]] 11:40~~, ~~15 September 2010 (CDT~~)

* 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.

* intake and output sheets

* CRRT sheets

* GCS sheets; neuro assessments are accessible via EPR flowsheets

== Related articles ==

[[Category:St Boniface Hospital Office (Medicine)]]

[[Category:St Boniface Hospital Office (Critical Care)]]

[[Category:Site Specific Collection Guide]]

[[Category:Hospital EPR]]

@@ Line 1: / Line 1: @@
-'''EPR''' -'''E'''lectronic''' P'''atient '''R'''ecord
+This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]].
-*also referred to as '''EHR''' - '''E'''lectronic '''H'''ealth ''' R'''ecord
-Currently only at the ST Boniface Hospital
+== Implementation Status ==
+All sites are at different stages of EPR implementation. It is fully implemented at STB.
-*What is EHR?- [http://www.manitoba-ehealth.ca/news.html EHR News]
+=== Data only documented in EPR ===
-**Phase 1 of EPR which includes patient registration information, labs, some patient information, billing information started April 12, 2007
+* data listed at [[EPR#Data in EPR]]
-**Phase 2A includes order entry, order management and medication worksheet for nurse documentation (MAR) was implemented between December 2008 to February 2009.
+<!-- anything else? Only list here if not already documented in general -->
+* Physician orders
+* laboratory
+* pharmacy data (MAR)
+* 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 ===
+* endoscopy has a paper version and an EPR version.
+* heart cath has both paper and EPR versions of the report.
-==eHealth-System Access Form==
+=== Data still recorded only outside of EPR / on paper ===
+* vital signs for apache from icu flowsheets,
-[http://intranet.sbgh.mb.ca/Forms/files/SBGHSystemAccessForm.doc STB-eHealth application form]
+* amount of blood products delivered from the blood transfusion record sheet
---[[User:TOstryzniuk|TOstryzniuk]] 11:40, 15 September 2010 (CDT)
+* 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.
+* intake and output sheets
+* CRRT sheets
+* GCS sheets; neuro assessments are accessible via EPR flowsheets
-{{stub}}
+== Related articles ==
+{{Related Articles}}
+[[Category:St Boniface Hospital Office (Medicine)]]
+[[Category:St Boniface Hospital Office (Critical Care)]]
+[[Category:Site Specific Collection Guide]]
+[[Category:Hospital EPR]]