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
 
Used to collect the laboratory and pharmacy data. As well it records admit and discharge times under patient registration.  
 
== to set up new collector ==
* [http://services.manitoba-ehealth.ca/acctManagement.html  ehealth Forms]
* 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
'''Sign by site Director.  '''
* book EPR training with STB site. Request FORM link:  [http://services.manitoba-ehealth.ca/acctManagement.html STB electronic ehealth request form]]
 


== 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 that include electronic clinical notes.
* 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
*1-1.5 hr The eLearning option is available on the Manitoba eHealth Learning Management System (LMS) and is available to all WRHA staff with WRHA or site based email accounts. STB Data Collector will have to complete online learning.  Email sent today with instruction how to log in and create account for LMS.-[[User:TOstryzniuk|Trish Ostryzniuk]] 21:53, 2012 November 21 (EST)
* 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]]


{{discussion}} StB folks - is ClinDoc rolled out now? Is the implementation complete? Ttenbergen 09:45, 2013 December 16 (CST)
=== 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.


=== Parts already implemented ===
=== Data still recorded only outside of EPR / on paper ===
**Phase 1 of EPR which includes patient registration information, labs, some patient information, billing information started April 12, 2007
* vital signs for apache from icu flowsheets,
**Phase 2A includes order entry, order management and medication worksheet for nurse documentation (MAR) was implemented between December 2008 to February 2009.  
* amount of blood products delivered from the blood transfusion record sheet
**ClinDoc: implementation dates:  Nov 2012 STB MICU, CCU, CICU.  Jan 2013 STB Med wards.
* 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


== Accessing Data on this EPR directly ==
== Related articles ==  
Dr Garland attempted to arrange that we get at least some data from this EPR directly but currently they don't have enough data analysts available to accomplish this. This was some months ago. Ttenbergen 09:48, 2013 December 16 (CST)
{{Related Articles}}


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

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:
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