STB Medicine Collection Guide: Difference between revisions

fixing and cleaning up unit links
cleared out some more content that is general curriculum or site-wide info
 
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This article contains information specific to STB Medicine, see the [[Medicine Curriculum]] for general information, and [[STB Collection Guide]] for St Boniface specific information.  
This article contains information specific to STB Medicine. '''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles. '''


''Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles. ''
*See '''[[STB General Collection Guide]]''' for general STB information such as: links to EPR, Mail room, medical records. Information also in regards to obtaining hand sanitizer, wipes, printer paper for collection offices.
*See '''[[Medicine Curriculum]]''' for general information
*See also:
** [[STB B5]]
** [[STB_E6_B]]
** [[STB E5]]
** [[STB EMIP]]
** [[STB A6ME]]


See also:
=== Services and Locations ===
* [[STB B5]]
==== Respiratory Service ====
* [[STB E6]]
* As per [[Definition of a Medicine Program Admission]] we do NOT collect data on the patients admitted under the Respiratory service.
* [[STB_A7_B]]
The Respiratory service admits patients to B5 under the SBGH Internal Med / Respiratory service. The number of beds that are occupied by these patients can fluctuate from day to day and as such so will the census for medicine patients that are admitted to B5. We d
* [[STB E5]]
*When a patient is discharged to B5 under the respiratory service the [[Dispo field]] should be STB_Ward, similarly if you admit a patient from B5 that was under the respiratory service the [[Admit from]] should be STB_ward
* [[STB EMIP]]
*We do collect nephrology patients that are admitted to B5.
* [[STB IMCU]]
== Location of information ==
We use EPR for all Admit/Transfer/Discharge times.


[[Accept DtTm]] is found under the orders tab, Transfers/Care Directives. You will see an "admit to inpatient order".
==== Nephrology Service ====
{{Discuss |
{{DL|There was a discussion about the beds that had been "handed to" them... what was the outcome, should it go here?}}
* Is that used for STB Critical Care Accept DtTm as well? If so, it needs to be moved to [[STB Collection Guide]] instead.
}}


[[Arrive DtTm]] is found by clicking on Registration (on top left bar), then Visit Location, then Location History. A new Location History window will pop up that will tell you the date & time that the patient arrived at a particular location. (e.g. patient arrived on E5 medicine from the emergency department.)
=== STB Swing Beds ===
{{Discuss |
*STB Swing Bed entries are "bed" records within a "unit" in EPR/Cognos. They are not beds or locations but conceptual service location and time entries used for patient moves. This data causes a patient record to show up in Cognos/CUS as having arrived on a unit even when the pt has not actually arrived, and it isn't visible in our listings whether the record is for a swing or real bed.
* Is that used for STB Critical Care Arrive DtTm as well? If so, it needs to be moved to [[STB Collection Guide]] instead.
*Since any CUS entry at STB may be either a swing bed or a real bed, service locations and times need review.
}}
For Medicine, the swing bed entries will often be obvious as the unit stays will be a matter of minutes
 
If a CUS entry is for a swing bed, manually exclude using the "exclude" button
See [[Visit Admit DtTm field]] for how to collect this field.
 
Transfers between different units can be found in the same Location History window as Arrive Date & Time and Visit Admit Date & Time.
 
[[Dispo_DtTm]] is found under the patient info tab, then clicking Demographics/Visit Data on the left. The discharge information will be on the bottom right of the page.
 
== [[Boarding Loc]] ==
Full-time [[Boarding Loc]] ward patients are captured on the E5 laptop only.
 
{{Discuss | Are they identified with [[Identifying patients in boarding locations]] or how? }}
 
== Workload distribution ==
See [[STB Medicine Workload splitting]]
 
== Vacation Coverage ==
*[[Vacation and staff shortage collection priorities]]? Should it be? Ttenbergen 18:35, 2016 November 10 (CST)
For those collectors who are doing vacation relief for the regular collectors who are away, catch up from time off can be expedited for the returning collector if the following things are prioritized.
 
#ADL's can be found on the [[STB Electronic Patient Record]]. They are in "initial assessment" form under the documents tab. Everything needed for minimal data will be included.
#medicine apache score. The SBGH ER unit is online with their vital signs and neuro assessment. This means that the vital signs and gcs required for the apache score can now be found under the flow sheets tab. To access neuro check, click on flow sheets, then care and assessment, then neuro. The only exception to this is for patients admitted to the unit from [[STB_MICU]]. [[STB_MICU]] does not use EPR (electronic patient record) for vital signs, and hence apache for these patients still need to be obtained from the paper flow sheet in the chart.  
 
[[Category:Vacation]]
 
== items not yet on electronic chart ==
=== APACHE tab ===
To collect the Medicine items on the Apache tab
* for patient who come from MICU, look on the the MICU flow sheet
* for all other patient use EPR vital signs
 
{{discuss|
* Just to be sure, does this still refer to a non-EPR process? If so please remove this discussion. If not, let's figure out where this fits in. Ttenbergen 13:56, 2017 July 18 (CDT)Ttenbergen 13:29, 2020 January 31 (CST)}}
 
== Office and staff ==
see [[:Category:St Boniface Hospital Office (Medicine)]]


== Related articles ==  
== Related articles ==  
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[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:St Boniface Hospital Office (Medicine)]]
[[Category:Site Specific Collection Guide]]
[[Category:Site Specific Collection Guide]]
[[Category: Data Collection Guide]]
[[Category:Data Collection Guide]]
[[Category:Overflow]]
[[Category:Overflow]]