STB Electronic Patient Record: Difference between revisions
Ttenbergen (talk | contribs) We now have a central definition for what to use for these times, so STB should no longer use special collection instructions for this. |
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== Implementation Status == | == Implementation Status == | ||
All sites are at different stages of EPR implementation. | All sites are at different stages of EPR implementation. This is a list of collection-related items and their implementation status. '''As this changes, also update [[STB Critical Care Collection Guide#Checklist for bedside data collection in STB ICUs]] to keep them consistent. ''' | ||
=== Data only documented in EPR === | === Data only documented in EPR === | ||
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* laboratory | * laboratory | ||
* pharmacy data (MAR) | * pharmacy data (MAR) | ||
* integrated progress notes | * 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 | * nurses operative report | ||
* physicians OR notes | * physicians OR notes | ||
* Central line insertions | * 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 === | === Data documented in paper and EPR === | ||
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=== Data still recorded only outside of EPR / on paper === | === Data still recorded only outside of EPR / on paper === | ||
* vital signs for apache from icu flowsheets, | * vital signs for apache from icu flowsheets, | ||
* amount of blood products delivered from the blood transfusion record sheet | * amount of blood products delivered from the blood transfusion record sheet | ||
* anesthesia record | * 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. | * 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 | * intake and output sheets | ||
* CRRT sheets | * CRRT sheets | ||
* GCS sheets | * GCS sheets; neuro assessments are accessible via EPR flowsheets | ||
== Related articles == | == Related articles == | ||