STB Electronic Patient Record: Difference between revisions

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~~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 ==

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]]

* Physician orders

* laboratory

* 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 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)~~

* 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 still recorded outside of~~ EPR ===

=== Data documented in paper and EPR ===

* ~~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~~.

* endoscopy has a paper version and an EPR version.

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

== ~~See also~~ ==

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

* [[EPR ~~Lists]]~~

* 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 ==

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

@@ 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 ==
-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
 * laboratory
 * 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 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)
+* 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 still recorded outside of EPR ===
+=== Data documented in paper and EPR ===
-* 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.
+* endoscopy has a paper version and an EPR version.
+* heart cath has both paper and EPR versions of the report.
-== See also ==
+=== Data still recorded only outside of EPR / on paper ===
-* [[EPR Lists]]
+* 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)]]