Lost/missing chart: Difference between revisions
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Sometimes charts go missing so we can't finish collection on a patient. Records like that have [[RecordStatus]] set to "[[RecordStatus#discontinued|discontinued]]". | |||
== Deferral period == | == Deferral period == | ||
*A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (same day number, 6 months later) after the patient has been discharged from the hospital or died in hospital. | *A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (same day number, 6 months later) after the patient has been discharged from the hospital or died in hospital. | ||
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* Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible | * Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible | ||
** This includes any diagnostic imaging and procedure counts and results, lab results, etc | ** This includes any diagnostic imaging and procedure counts and results, lab results, etc | ||
* Where you can not get past a cross check because data is not available, explain that in the [[Notes field]] | * Where you can not get past a [[cross check]] because data is not available, explain that in the [[Notes field]] | ||
* Regarding APACHE variables for these charts: | * Regarding APACHE variables for these charts: | ||
**Usually we consider variables that are missing to be normal values. But for these charts we cannot do so, so while you should code those APACHE variables for which there IS data, for those APACHE variables for which there is no data, enter the numeric code for "missing" i.e. the negative number -999 | **Usually we consider variables that are missing to be normal values. But for these charts we cannot do so, so while you should code those APACHE variables for which there IS data, for those APACHE variables for which there is no data, enter the numeric code for "missing" i.e. the negative number -999 | ||
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=== Instructions for Data Processor === | === Instructions for Data Processor === | ||
[[Category:Data Processing]] | [[Category:Data Processing]] | ||
The Data Processor will manually set the [[RecordStatus]] for these to "Discontinued"; information on the lost chart status can be entered into the [[Notes]] field. | The Data Processor will manually set the [[RecordStatus]] for these to "Discontinued"; information on the lost chart status can be entered into the [[Notes]] field. | ||
A line is also added to [[L Problem table]] for each discontinued record: | |||
* D_ID | |||
* Query - blank | |||
* Notes - any known info about why discontinued, and what is available | |||
=== Excluded from reporting === | |||
Discontinued charts are excluded from cross-checks, reporting and other data extracts. <!-- JALT 2022-08-04 --> | |||
== Log == | |||
As of 2022-03 all "lost chart" records have been set to [[RecordStatus]] "discontinued" and documented in [[L Problem table]]. | |||
== Related articles == | == Related articles == | ||
{{Related Articles}} | {{Related Articles}} | ||
[[Category: Data Collection Guide]] | [[Category:Data Collection Guide]] | ||