STB Electronic Patient Record: Difference between revisions

From CCMDB Wiki
Jump to navigation Jump to search
mNo edit summary
No edit summary
(49 intermediate revisions by 5 users not shown)
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'''
*What is EHR?- [http://www.manitoba-ehealth.ca/news.html EHR News]
**Phase 1 of EPR which includes patient registration information, labs, some patient information, billing information started April 12, 2007
**Phase 2A includes order entry, order management and medication worksheet for nurse documentation (MAR) was implemented between December 2008 to February 2009.
== Implementation Status ==
== Implementation Status ==
We are in phase 2 of electronic patient record implementation. This means that all patient log data, location information, lab and diagnosis imaging results, tests, physicians’ orders and pharmacy are obtained electronically.  Eventually all data will be obtained electronically.
All sites are at different stages of EPR implementation. It is fully implemented at STB.


== Clindoc ==
=== Data only documented in EPR ===
This is the next Phase of EPR at STB.
* data listed at [[EPR#Data in EPR]]
*CICU & CCU - Starting end of November 2012 
<!-- anything else? Only list here if not already documented in general -->
*Medicine/MICU/SICU - current plan start sometime January 2013
* Physician orders
*3 hr online learning program plus a 4 hr class inservice.  Data Collectors at thist site will have to attend. [[User:TOstryzniuk|Trish Ostryzniuk]] 13:19, 2012 October 31 (EDT)
* 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]]


== eHealth System Access ==
=== Data documented in paper and EPR ===
* [http://intranet.sbgh.mb.ca/Forms/files/SBGHSystemAccessForm.doc STB-eHealth application form]
* endoscopy has a paper version and an EPR version.
* eHealth needs to be informed of any new or replacement computer that needs to access the EPR, it needs to be added to a list. An email to the service desk with the PC name should do the trick
* heart cath has both paper and EPR versions of the report.  
 
=== Data still recorded only outside of EPR / on paper ===
* vital signs for apache from icu flowsheets,
* amount of blood products delivered from the blood transfusion record sheet
* 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 ==
{{Related Articles}}


[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:St Boniface Hospital Office (Critical Care)]]
[[Category:St Boniface Hospital Office (Critical Care)]]
[[Category:Site Specific Collection Guide]]
[[Category:Site Specific Collection Guide]]
[[Category:Hospital EPR]]

Revision as of 10:42, 12 December 2025

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

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

Data only documented in EPR

  • data listed at EPR#Data in EPR
  • 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.

Data still recorded only outside of EPR / on paper

  • vital signs for apache from icu flowsheets,
  • amount of blood products delivered from the blood transfusion record sheet
  • 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

Related articles: