STB Electronic Patient Record

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
• 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