Notes field

Data Element (edit)
Field Name:	Notes
CCMDB Label:	Notes
CCMDB tab:	Top Row
Table:	L_Log table
Data type:	memo
Length:	not stated
Program:	Med and CC
Created/Raw:	Raw
Start Date:	1988-07-11
End Date:	2300-01-01
Sort Index:	9

Used by data collectors to keep notes during collection.

• SMW

Legacy implementation right in the table

• Cargo

• Categories

• Forms

The notes field expands to a bigger form when you double-click on it.

Usage of the notes field

The notes field was set up to be a free-for-all where collectors can store any info they want. This resulted in non-standardized collection practices which result in problems during vacation coverage or on shared wards.

Guidelines

• Please do not write copious history notes from charts into this note section. This is only for reminders or points needed to do your work, dates where you left off at or any follow up of info, test etc., that need to be done by yourself or for others who help collect on your laptop. Notes have to be clear to others.

Patients being sent

• For patients you are ready to send, make sure you note explanations for data values that you think might cause call-backs from the Data Processor or Statistician. For example:
• Extreme data that was confirmed as correct:
  • extreme physiological APACHE values, eg Sys BP of 50 valid , see APACHE_Scoring_table and APACHE_physiological_variable_collection#Exceptionally_high_or_low_values
  • to verify imaging counts ie. 2 day LOS and 12 CXR's done, you may want to write a short note that the imaging counts are correct or have been double checked
  • Some are using this for VAP adjudication criteria, these notes can stay in case there are future questions re. VAP
• Upon review of the Notes field, and prior to sending, please delete any data that would not be used to clarify extreme data or outliers. The main office will use this to clarify extreme data, so deleting excess data in this field will help streamline this process for the main office.

Up-to where/when collection is complete

• STB - where we have left off reading in the EPR notes by entering the date/time last read
• HSC- where we have left off checking orders, pharm, counting EPR labs, reading notes by entering the date/time last read.

Diagnoses or other data that needs to be reviewed or checked

Can be used to document suspected diagnoses (which would not be coded in ICD10 even for incomplete records, as per ICD10 collection#"Suspected" Diagnoses.

Supplemental data

• to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
  • be aware that 99% diagnosis data analysis in the main office will not look at the notes field, as usually there are just filters or counts on the ICD10 dx entries.

• to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.

• to define what exactly needs to be entered, when a profile is only partially completed.

Automatic population of notes field for newly entered patients

We tried to standardize field into a kind of form, but collection practice is too non-standard to come up with a format that worked.

Just being curious if the notes field is a free space for optional additional info....what specific problems did this cause? I actually prefer a blank notes field. The premise was good but turns out to not be all that helpful.--CMarks 11:53, 2018 December 6 (CST) Recently a format was implemented and placed into the notes field. We would like to know if this format is helpful and if you use it. Please indicate here if you use it or not and any comments you would like to make regarding this: Laura: I find the guidelines written in this article are sufficient information for the notes field to give tips for usage. If anyone has difficulty when they are covering for someone else, they just need to ask what is meant by specific entries. I would like to speak to anyone who has difficulty. I feel that the notes section is not only used differently for different collectors but also in different scenarios. I like that it allows for individual needs and allows some freedom for any use that each collector may require. The current format is not user friendly and I just wonder who actually is using it. I personally would prefer a blank note field. --LKolesar 07:49, 2018 December 6 (CST) I too, would just prefer a blank note field. As good as the idea for dates and times was, the format just wasn't what I use. DPageNewton 07:57, 2018 December 6 (CST) I do not find this useful or user friendly. I much prefer a blank field so we can enter what we need. Lois I modify the format to suit my needs, so I am not using it as intended. It is less convenient than how I was writing in date and time read up to before the change was made. Good idea, but didn't quite work for me.Mlagadi 08:25, 2018 December 6 (CST) While I appreciate the intent to assist data collectors with collection, I find the current format not helpful. I agree with Laura regarding data collectors having differing needs/preferences, and the best way to accommodate all data collectors would be a blank notes field Pamela Piche 08:45, 2018 December 6 (CST) I prefer a blank note field Lisa Kaita 09:39, 2018 December 6 (CST) I also prefer the note field to be blank. It takes just a few seconds to erase but it's a few seconds I don't have to spare. --mvpenner 10:29, 2018 December 6 (CST)