STB Electronic Patient Record: Difference between revisions
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This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]]. | |||
== Implementation Status == | |||
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 listed at [[EPR#Data in EPR]] | |||
<!-- anything else? Only list here if not already documented in general --> | |||
* Physician orders | |||
* laboratory | |||
* pharmacy data (MAR) | |||
* 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 | |||
* physicians OR notes | |||
* 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 === | |||
* endoscopy has a paper version and an EPR version. | |||
* heart cath has both paper and EPR versions of the report. | |||
{ | === Data still recorded only outside of EPR / on paper === | ||
* vital signs for apache from icu flowsheets, | |||
* amount of blood products delivered from the blood transfusion record sheet | |||
* 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. | |||
* intake and output sheets | |||
* CRRT sheets | |||
* GCS sheets; neuro assessments are accessible via EPR flowsheets | |||
== Related articles == | |||
{{Related Articles}} | |||
[[Category:St Boniface Hospital Office (Medicine)]] | |||
[[Category:St Boniface Hospital Office (Critical Care)]] | |||
[[Category:Site Specific Collection Guide]] | |||
[[Category:Hospital EPR]] | |||