|
|
| (17 intermediate revisions by 3 users not shown) |
| Line 1: |
Line 1: |
| See [[EPR Gateway]] for regional access to EPR used by all collectors.
| | 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 == |
| All sites are at different stages of EPR implementation. Please list what is included at your site here: | | All sites are at different stages of EPR implementation. It is fully implemented at STB. |
| * fully implemented at STB | | |
| | === Data only documented in EPR === |
| | * data listed at [[EPR#Data in EPR]] |
| | <!-- anything else? Only list here if not already documented in general --> |
| * Physician orders | | * Physician orders |
| * laboratory | | * laboratory |
| * pharmacy data (MAR) | | * pharmacy data (MAR) |
| * admit and discharge times under patient registration
| | * 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 |
| * integrated progress notes | | * nurses operative report |
| | | * physicians OR notes |
| *As of January, 2013, all chart information is found in the Electronic Patient Record for MICU except: The nurses flow sheets, OR records, ER records, Echo Reports, Endoscopy reports, heart cath. reports, central line insertion sheets, blood product sheets. (These items are still part of the paper chart). --[[User:LKolesar|LKolesar]] 11:42, 2013 May 6 (EDT)
| | * Central line insertions |
| *As of September, 2017, the nurses operative report is in EPR under documents. The physicians OR notes have been in EPR for some time. Central line insertions are put in EPR under documents, endoscopy has a paper version and an EPR version. The heart cath has both paper and EPR versions of the report. ER is mostly all EPR now. The only exclusive paper reports are echo reports and the anesthesia record. Other paper elements include blood product sheets, nurses flow sheets, intake and output sheets, CRRT sheets & GCS sheets.--[[User:LKolesar|LKolesar]] 12:40, 2017 September 7 (CDT) | | * diagnostic imaging, including echocardiograms |
| | | * Cardiac Catheterization reports; access results via link to the right of the document |
| === data still recorded outside of EPR ===
| | * Results for intraop echo for the [[Project ABO TEE]] |
| * [[Media:!Nursing Discharge Screening Tool WRHA January 2014.pdf| Discharge Planning Screening Tool form (DPST Form)]] | |
| * We still access time of icu admission, continuous medication infusions and vital signs for apache from icu flowsheets, and check amount of blood products delivered from the blood transfusion record sheet, and TEE reports for patients having OHS. | |
| | |
| ===HOW TO MAKE A BASIC VISIT LIST===
| |
| *Actions tab- click on new visit list. | |
| *Your role tab-leave blank
| |
| *Location tab-click on "include pts at selected locations only"
| |
| *Then, double click on specific hospital
| |
| *Then, click on "inpatient"
| |
| *Then, click on the specific ward or icu desired for the list
| |
| *Then, click "add".
| |
| *Then, OK
| |
| *Then, a pop up will ask what name you want to give your new list, you type in the name ie MICU.
| |
| *Then OK, should show the current list for that unit.
| |
|
| |
|
| NOTE: Lists can be made with other criteria but these instructions are only the basic visit list for current patients.
| | === 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. |
|
| |
|
| Other possible criteria examples: discharged patients, list of patients admitted in last few days. There are too many possible options to list here. --[[User:LKolesar|LKolesar]] 12:02, 2014 October 24 (CDT)
| | === 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)]] |