Lost/missing chart

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.
• Once that occurs, the record status will be updated to "Discontinued".
• Operationally, this will be done via ad hoc communication with the office (Pagasa).

Instructions for finishing off the profile

An profile for a missing chart might trigger CCMDB.accdb Data Integrity Checks, so it can't be sent the normal way and the following process applies instead.

Instructions for Collectors

• 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
• 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:
  • 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
    • Entering this will, of course, trigger cross-checks, but that's OK since you won't be able to set the RecordStatus to "complete" anyway
• You probably won't be able to set the RecordStatus to "complete" since there will be data missing; even if you are able to, don't set the record to "complete"
• When you have entered all available information, and when the #Deferral period has passed, contact Pagasa and tell her the profile is a missing/lost chart
• Once Pagasa has confirmed that this is understood and set the RecordStatus to 'Discontinued", delete the chart using the ♻️ button

Instructions for Data Processor

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.

Log

As of 2022-03 all "lost chart" records have been set to RecordStatus "discontinued" and documented in L Problem table.