Notes field: Difference between revisions
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===Guidelines=== | ===Guidelines=== | ||
*Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others. | *Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others. | ||
=== Patients being sent === | === Patients being sent === | ||
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* Extreme data that was confirmed as correct: | * Extreme data that was confirmed as correct: | ||
** extreme physiological APACHE values, eg Sys BP of 50 valid , see [[APACHE_Scoring_table]] and [[APACHE_physiological_variable_collection#Exceptionally_high_or_low_values]] | ** extreme physiological APACHE values, eg Sys BP of 50 valid , see [[APACHE_Scoring_table]] and [[APACHE_physiological_variable_collection#Exceptionally_high_or_low_values]] | ||
** | ** to verify imaging counts ie. 2 day LOS and 12 CXR's done, you may want to write a short note that the imaging counts are correct or have been double checked | ||
** Some are using this for VAP adjudication criteria, these notes can stay in case there are future questions re. VAP | |||
*Upon review of the Notes field, and prior to sending, please delete any data that would not be used to clarify extreme data or outliers. The main office will use this to clarify extreme data, so deleting excess data in this field will help streamline this process for the main office. | |||
==== Up-to where/when collection is complete ==== | ==== Up-to where/when collection is complete ==== | ||
* STB - where we have left off reading in the EPR notes by entering the date/time last read | * STB - where we have left off reading in the EPR notes by entering the date/time last read | ||
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==== Supplemental data ==== | ==== Supplemental data ==== | ||
* to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them. | * to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them. | ||
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{{Related Articles}} | {{Related Articles}} | ||
[[Category: Data Collection Guide]] | [[Category:Data Collection Guide]] | ||
[[Category: CCMDB.accdb]] | [[Category:CCMDB.accdb]] | ||