Project AHC: Difference between revisions
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'''As of 2025-07-02, this project only runs at GRA.''' | '''As of 2025-07-02, this project only runs at GRA.''' | ||
== Data Collection == | == Data Collection applicable for... == | ||
* For any medicine record being sent after the project start date, capture | * For any medicine record being sent after the project start date, capture the first consult for OT, PT, Social Work and Home Care. The reason for the consult does not matter. | ||
* | ** OT said sometimes the medicine team will write a new consult, but that it isn't necessary if they are already following, they will however write a "transfer" note. she was uncertain if all other allied health teams practice the same way. Many of the consults are verbal. - '''you would enter a re-consult written as that''' | ||
=== Exclusion === | |||
* | * we don't track consults for | ||
** pharmacy | |||
** utilization | |||
collect only the first consult sent dttm (or received if no indication of when the consult was sent) | |||
== Data Entry Instructions == | == Data Entry Instructions == | ||
The following instructions hold for one of each of the allied health teams, ie AH_C_OT, AH_C_PT, AH_C_SW, AH_C_HC | * The following instructions hold for one of each of the allied health teams, ie AH_C_OT, AH_C_PT, AH_C_SW, AH_C_HC | ||
Same instructions for each unless otherwise noted. | * Same instructions for each unless otherwise noted. Acronym definitions: AH_C - Allied Health Consult, OT - Occupational Therapy, PT - Physical Therapy(Physiotherapy), SW - Social Work, HC - Home Care. | ||
* Conditional formatting per allied health team: PT blue, OT yellow, SW green, HC red. | |||
=== Referral sent === | === Referral sent === | ||
A line with Project '''"AH_C_<the allied health team>_s"''' and item "Referral sent" will be entered automatically for new patients, existing records entered prior to the start date of the project will need to have these entered manually. | |||
* Project '''"AH_C_<the allied health team>_s"''' | |||
Update the record as follows: | Update the record as follows: | ||
* '''Item''': | * '''Item''': | ||
** '''"Referral sent"''' - leave this entry in place if a referral | ** '''"Referral sent"''' - leave this entry in place if a referral is found | ||
** '''"not consulted"''' - if you have finished the chart and didn't find one; '''in this case no other data for that consult should be entered, and any other lines generated for the respective allied health team should be deleted | ** '''"not consulted"''' - if you have finished the chart and didn't find one; '''in this case no other data for that consult should be entered, and any other lines generated for the respective allied health team should be deleted | ||
* '''Date''': date of the consult if available | * '''Date''' / '''Time''': date/time of the consult if available | ||
* | ** if consult not in chart but there is clear documentation in the chart use the dttm of the first note/assessment (best guess better than nothing but not mandatory) | ||
** time of the consult is not mandatory, but a best guess would be preferred over not entering it | |||
* '''Checkbox''': check if the date and/or time is a '''best guess''' | * '''Checkbox''': check if the date and/or time is a '''best guess''' | ||
* | * Integer, Real, Comment: not used | ||
=== Consult Received === | === Consult Received === | ||
The following lines will automatically be added to each new medicine record, existing records entered prior to the start date of the project will need to have these entered manually: | The following lines will automatically be added to each new medicine record, existing records entered prior to the start date of the project will need to have these entered manually: | ||
* '''Project: AH_C_<the allied health team>''' - Item: "not entered" (because you haven't set a value yet) | * '''Project: AH_C_<the allied health team>''' - Item: "not entered" (because you haven't set a value yet) | ||
Update the record as follows: | Update the record as follows: | ||
* '''Item''': change the item dropdown as follows as you come across information | * '''Item''': change the item dropdown as follows as you come across information | ||
| Line 48: | Line 45: | ||
** '''"aware of patient transfer from other source"''' - alternative if noted by AH | ** '''"aware of patient transfer from other source"''' - alternative if noted by AH | ||
** '''"Late consult received"''' - alternative if noted by AH | ** '''"Late consult received"''' - alternative if noted by AH | ||
* '''Date''' | * '''Date'''/'''Time''': date/time the consult is received, only if clearly documented | ||
* '''Checkbox''': check if the date and/or time is '''not documented''' | * '''Checkbox''': check if the date and/or time is '''not documented''' | ||
* ''' | * Integer, Real, Comment: not used | ||
* | |||
=== Sources === | |||
* SBGH in EPR - check for consults in the orders tab, there will also be documentation in the documents section by the various allied health teams, if they have been consulted | |||
* HSC and GGH - check for an order and also the consult sections of the chart, there will also be documentation in the notes section by the various allied health team, if they have been consulted | |||
== Special Cases == | |||
=== Special Case - Consult before admission or after discharge from medicine === | |||
{{DL | | |||
The following was written within the data entry instructions: "** for consults that are initiated prior to the first [[Service tmp entry]] use the dttm of the first [[Service tmp entry]]". But down here it seems to say to only enter that there was a consult if the the med team writes a new order, in which case there would be a new dttm that is within range. So these seem contradictory to me. Am I missing something? [[User:Ttenbergen|Ttenbergen]] 16:46, 21 November 2025 (CST) | |||
}} | |||
* Only enter yes, if the medicine team writes a new order to consult one of the allied health team. | |||
** OT said that if one of the OT members is consulted in ICU, or another ward, or ER, they do not re-consult, they give an OT to OT report - '''don't enter that''' | |||
{{DL| | |||
* is this really a "don't enter that"? If so it should go under [[#Exclusion]]. [[User:Ttenbergen|Ttenbergen]] 16:46, 21 November 2025 (CST) | |||
* or is it an "aware of patient transfer from other source" for "consult received" - in which case it should be a sub-bullet under that entry | |||
}} | |||
=== Special Case - Self-consults / verbal consults === | |||
* Self-consults by any allied health professional should be captured as a new consult | |||
* Verbal consults will not have an order or consult written, if when reviewing a chart there is a note by an allied health professional and no associated consult/order enter that as yes and note the dttm of the first documentation | |||
=== Special Case - Home care consults at GRA === | |||
* At the GGH patients who are already receiving Homecare services will have a printout from the EHCR (electronic home care record??) in the chart, choose the option "aware of patient transfer from other source" if this is the case. The date and time that the EHCR is printed will be on the form | |||
=== Special Case - Consult via Care Map === | |||
* for consult that are initiated via care maps/clinical pathways | |||
** use the dttm that the form is initiated | |||
** if there is no time indicated, use the date and time of arrival to the unit (ie initial [[Boarding Loc]] entry for the unit | |||
=== Special Case - Consult ordered and cancelled === | |||
* If there is an order to consult one of the AHC professionals, and it is later cancelled (doesn't matter how long after the order) then '''capture the consult''' | |||
== Data Use == | |||
This data is being collected as a current state for [[Project Overstay2]]. | |||
=== Legacy Collection Instructions (for data interpretation) === | |||
{{Collapsable | always=legacy collection instructions | full= | |||
'''As of 2025-10-09, collect only the first consult sent dttm (or received if no indication of when the consult was sent)''' | |||
The rest of these no longer apply for collection but are being maintained for data interpretation. | |||
* For any medicine record being sent after the project start date, capture whether there were any allied health consults, the reason for the consult does not matter. | |||
* Some patients may have more than one consult for the same allied health professional during their hospital stay, record each time there is a new consult for any of the allied health professions listed. | |||
** If there is more than one consult, link together the data collected per consult by entering a common number in the integer / "N" column; start with the number 100 so three is no confusion with other tmp entries that use the integer to link | |||
* self-consults by any allied health professional should be captured as a new consult | |||
* Verbal consults will not have an order or consult written, if when reviewing a chart there is a note by an allied health professional and no associated consult/order enter that as yes and note the dttm of the first documentation | |||
* If there is an order to consult one of the AHC professionals, and it is later cancelled (doesn't matter how long after the order) then capture the consult | |||
=== Optional Entries === | === Optional Entries === | ||
| Line 88: | Line 130: | ||
* Date, Time', Checkbox, Integer, Real, Comment: not used | * Date, Time', Checkbox, Integer, Real, Comment: not used | ||
}} | |||
{{Data Integrity Check List|}} <!-- this will populate automatically from the cross-checks --> | {{Data Integrity Check List|}} <!-- this will populate automatically from the cross-checks --> | ||
{{DT| can you please activate this cross check? thank you 14:13, 21 November 2025 (CST) }} | |||
== Related articles == | == Related articles == | ||
Latest revision as of 23:33, 21 November 2025
| Projects | |
| Active?: | active |
| Program: | Med |
| Requestor: | Dan Roberts |
| Collection start: | 2025-07-02 |
| Collection end: | |
As of 2025-07-02, this project only runs at GRA.
Data Collection applicable for...
- For any medicine record being sent after the project start date, capture the first consult for OT, PT, Social Work and Home Care. The reason for the consult does not matter.
- OT said sometimes the medicine team will write a new consult, but that it isn't necessary if they are already following, they will however write a "transfer" note. she was uncertain if all other allied health teams practice the same way. Many of the consults are verbal. - you would enter a re-consult written as that
Exclusion
- we don't track consults for
- pharmacy
- utilization
collect only the first consult sent dttm (or received if no indication of when the consult was sent)
Data Entry Instructions
- The following instructions hold for one of each of the allied health teams, ie AH_C_OT, AH_C_PT, AH_C_SW, AH_C_HC
- Same instructions for each unless otherwise noted. Acronym definitions: AH_C - Allied Health Consult, OT - Occupational Therapy, PT - Physical Therapy(Physiotherapy), SW - Social Work, HC - Home Care.
- Conditional formatting per allied health team: PT blue, OT yellow, SW green, HC red.
Referral sent
A line with Project "AH_C_<the allied health team>_s" and item "Referral sent" will be entered automatically for new patients, existing records entered prior to the start date of the project will need to have these entered manually.
- Project "AH_C_<the allied health team>_s"
Update the record as follows:
- Item:
- "Referral sent" - leave this entry in place if a referral is found
- "not consulted" - if you have finished the chart and didn't find one; in this case no other data for that consult should be entered, and any other lines generated for the respective allied health team should be deleted
- Date / Time: date/time of the consult if available
- if consult not in chart but there is clear documentation in the chart use the dttm of the first note/assessment (best guess better than nothing but not mandatory)
- time of the consult is not mandatory, but a best guess would be preferred over not entering it
- Checkbox: check if the date and/or time is a best guess
- Integer, Real, Comment: not used
Consult Received
The following lines will automatically be added to each new medicine record, existing records entered prior to the start date of the project will need to have these entered manually:
- Project: AH_C_<the allied health team> - Item: "not entered" (because you haven't set a value yet)
Update the record as follows:
- Item: change the item dropdown as follows as you come across information
- "referral received" - formal or informal (phone call, conversation, rounds conversation noted in IPN, etc)
- "aware of patient transfer from other source" - alternative if noted by AH
- "Late consult received" - alternative if noted by AH
- Date/Time: date/time the consult is received, only if clearly documented
- Checkbox: check if the date and/or time is not documented
- Integer, Real, Comment: not used
Sources
- SBGH in EPR - check for consults in the orders tab, there will also be documentation in the documents section by the various allied health teams, if they have been consulted
- HSC and GGH - check for an order and also the consult sections of the chart, there will also be documentation in the notes section by the various allied health team, if they have been consulted
Special Cases
Special Case - Consult before admission or after discharge from medicine
|
The following was written within the data entry instructions: "** for consults that are initiated prior to the first Service tmp entry use the dttm of the first Service tmp entry". But down here it seems to say to only enter that there was a consult if the the med team writes a new order, in which case there would be a new dttm that is within range. So these seem contradictory to me. Am I missing something? Ttenbergen 16:46, 21 November 2025 (CST) |
- Only enter yes, if the medicine team writes a new order to consult one of the allied health team.
- OT said that if one of the OT members is consulted in ICU, or another ward, or ER, they do not re-consult, they give an OT to OT report - don't enter that
|
Special Case - Self-consults / verbal consults
- Self-consults by any allied health professional should be captured as a new consult
- Verbal consults will not have an order or consult written, if when reviewing a chart there is a note by an allied health professional and no associated consult/order enter that as yes and note the dttm of the first documentation
Special Case - Home care consults at GRA
- At the GGH patients who are already receiving Homecare services will have a printout from the EHCR (electronic home care record??) in the chart, choose the option "aware of patient transfer from other source" if this is the case. The date and time that the EHCR is printed will be on the form
Special Case - Consult via Care Map
- for consult that are initiated via care maps/clinical pathways
- use the dttm that the form is initiated
- if there is no time indicated, use the date and time of arrival to the unit (ie initial Boarding Loc entry for the unit
Special Case - Consult ordered and cancelled
- If there is an order to consult one of the AHC professionals, and it is later cancelled (doesn't matter how long after the order) then capture the consult
Data Use
This data is being collected as a current state for Project Overstay2.
Legacy Collection Instructions (for data interpretation)
| legacy collection instructions |
|
As of 2025-10-09, collect only the first consult sent dttm (or received if no indication of when the consult was sent) The rest of these no longer apply for collection but are being maintained for data interpretation.
Optional EntriesAllied Health wants to work on improving the process and has asked us to track a few options if they occur. For these, rely on AH to enter these right with their IPN note, ie collectors are not required to interpret or adjudicate this. This has been discussed with Allied health. Item options are:
Consult Dealt WithThe following lines will automatically be added to each new medicine record, existing records entered prior to the start date of the project will need to have these entered manually:
Update the record as follows:
Consult DischargedIf there is a specific record (see #Optional Entries) that the patient was discharged by allied health, then enter:
|
Data Integrity Checks (automatic list)
| App | Status | |
|---|---|---|
| Query check_tmp_AHC | CCMDB.accdb | needs review |
Related articles
| Related articles: |