Minimal Data Set: Difference between revisions

(121 intermediate revisions by 9 users not shown)

Line 1:

The '''Minimal Data Set''' is the least amount of data that needs to be collected for a new patient when they are first [[adding a patient | added]] to the database. This data is [[Sending Patients | sent]] every ~~week~~ for '''all patients''', not just those ~~who~~ are ~~[[Final Check]]ed~~. This data needs to be entered for '''all newly admitted patients''' during '''every data collection shift'''. With the exception of special requests from ~~head~~ office, it is more important to collect this data than to complete collection for existing patients, '''especially for incomplete files'''.

The '''Minimal Data Set''' is the least amount of data that needs to be collected for a new patient when they are first [[adding a patient | added]] to the database. This data is [[Sending Patients | sent]] every shift worked for '''all patients''', not just those you are sending. This data needs to be entered for '''all newly admitted patients''' during '''every data collection shift'''. With the exception of special requests from the [[:Category:Main Office | main office]], it is more important to collect this data than to complete collection for existing patients, '''especially for incomplete files'''.

If you '''try to send''' with ~~part A~~ of the ~~minimal data set~~ '''incomplete for any patient''' (even ones ~~who~~ are not ~~[[Final Check]]ed~~), the [[CCMDB.~~mdb~~]] will give an "incomplete minimal data set" error and list the patient, and you will not be able to send '''any''' patients.

If you '''try to send''' with any of the core Minimal Data Set Elements '''incomplete for any patient''' (even ones you are not completing), the [[CCMDB.accdb]] will give an "incomplete minimal data set" error and list the patient, and you will not be able to send '''any''' patients.

==Minimal Data Set Elements ==

== Minimal Data Set Elements-Primary==

*A. For all new patients at every shift:

For all '''new''' patients at every shift enter the following from EPR:

** serial number

* [[Serial number]]

** hospital

* [[Service/Location]]

** unit / location

* [[First Name]]

** first name

* [[Last Name]]

** last name

* [[PHIN field|PHIN]]

** hospital ~~chart~~ number

* hospital [[Chart number]]

** [[Admit~~%2C_Transfer_and_Discharge_date_and_time#Admit_Date_and_Time~~ | ~~admit date~~]]

* hospital [[Visit Admit DtTm field | Visit Admit DtTm]]

*** ~~time should be entered if available, but will not generate an error if not entered since it is often not available immediately.~~

* [[Date of Birth| Date of Birth (DOB)]]

* first [[Boarding Loc]] - start_dt and start_tm

* first [[Service tmp entry]] - start_dt and start_tm

*B. For existing patients at every shift, add as they become available:

== Additional elements for [[Overstay2 Overview|Overstay]] ==

** admit '''time'''

Sites involved in [[Project Overstay2]] also need to add the elements required for that on admission. See [[Project Overstay2#Data required in addition to Minimal Data Set]].

** discharge date and time (this should be entered within '''ONE week''' of discharge - this date is important for ~~occupancy report which includes reporting the number of outstanding incomplete files.)~~

** PHIN

** DOB

~~The absence of these two items~~ in ~~Part B, will not stop~~ the ~~CCMDB from sending files~~. ~~These items are allowed to be empty since they may not be available initially, but they should be filled~~ in ~~'''as soon as available.''' '''The Discharge Date''' is most important~~ to ~~enter into data ASAP~~.

==~~Instruction for STB Med Minimal Data Set - Primary Source for the Admit date/time to Medicine Service:~~==

== Ideal elements ==

*~~a. For Acute Care Medicine patients at STB, use~~ the ~~Doctors orders~~ on ~~the EPR as date/time accepted to Medicine Service.--~~[[~~User:TOstryzniuk|TOstryzniuk~~]] ~~17:26, 21 September 2010 (CDT)~~

* [[Postal Code]] should be included if available from [[Cognos]] but is known to sometimes change during the admission; we don't expect collectors to quality check this on incomplete records

*b. for Non Acute Care - C service medicine patients at STB, use EPR's registration tab/visit location/location history, ~~for date/time accepted to medicine service.~~

* [[Previous Location]] should be entered if easily available from Cognos data, but is not required if it requires further data review

~~{{discussion}}~~

== Reason why data is required for patients with [[RecordStatus]] incomplete ==

~~=== Minimal data set only??===~~

Data in the minimal data set is sent for all patients as soon as available, even before the patient's [[RecordStatus field]] is set to "complete". This allows us to include counts of longer-stay patients who have not yet been discharged in our statistics and reporting.

Do these instructions apply to the minimal data set only, or to all Admit date/time entries? If so, [[Admit%2C_Transfer_and_Discharge_date_and_time#Definition_for_Medicine]] should be amended with this and it should be removed from here. [[User:Ttenbergen|Ttenbergen]] 14:40, 1 November 2010 (CDT)

== Reason why data is required for patients ~~that are not complete yet~~ ==

Data in the minimal data set is sent for all patients as soon as available, even before the patient is ~~final checked~~. This allows us to include longer-stay patients who have not yet been discharged in our statistics and reporting.

Data from patients who are not yet complete is used for the following:

* to generate occupancy statistics

* to be able to finalize temporary studies before long-stay patients are eventually discharged

* to monitor the number of outstanding patients

Minimal dataset information can be used for reporting; we will include a caveat that it is preliminary and not yet quality checked. We will not do additional [[cross check]]s to validate minimal dataset data on incomplete records.

== Related articles ==

[[Category: Data Collection Guide]]

[[Category:Registry Data| *]]

[[Category: ~~IT Instructions~~]]

[[Category:Data Collection Guide]]

[[Category:2016 Time and Place changes]]

@@ Line 1: / Line 1: @@
-The '''Minimal Data Set''' is the least amount of data that needs to be collected for a new patient when they are first [[adding a patient | added]] to the database. This data is [[Sending Patients | sent]] every week for '''all patients''', not just those who are [[Final Check]]ed. This data needs to be entered for '''all newly admitted patients''' during '''every data collection shift'''. With the exception of special requests from head office, it is more important to collect this data than to complete collection for existing patients, '''especially for incomplete files'''.
+The '''Minimal Data Set''' is the least amount of data that needs to be collected for a new patient when they are first [[adding a patient | added]] to the database. This data is [[Sending Patients | sent]] every shift worked for '''all patients''', not just those you are sending. This data needs to be entered for '''all newly admitted patients''' during '''every data collection shift'''. With the exception of special requests from the [[:Category:Main Office | main office]], it is more important to collect this data than to complete collection for existing patients, '''especially for incomplete files'''.
-If you '''try to send''' with part A of the minimal data set '''incomplete for any patient''' (even ones who are not [[Final Check]]ed), the [[CCMDB.mdb]] will give an "incomplete minimal data set" error and list the patient, and you will not be able to send '''any''' patients.
+If you '''try to send''' with any of the core Minimal Data Set Elements '''incomplete for any patient''' (even ones you are not completing), the [[CCMDB.accdb]] will give an "incomplete minimal data set" error and list the patient, and you will not be able to send '''any''' patients.
-==Minimal Data Set Elements ==
+== Minimal Data Set Elements-Primary==
-*A. For all new patients at every shift:
+For all '''new''' patients at every shift enter the following from EPR:
-** serial number
+* [[Serial number]]
-** hospital
+* [[Service/Location]]
-** unit / location
+* [[First Name]]
-** first name
+* [[Last Name]]
-** last name
+* [[PHIN field|PHIN]]
-** hospital chart number
+* hospital [[Chart number]]
-** [[Admit%2C_Transfer_and_Discharge_date_and_time#Admit_Date_and_Time | admit date]]
+* hospital [[Visit Admit DtTm field | Visit Admit DtTm]]
-*** time should be entered if available, but will not generate an error if not entered since it is often not available immediately.
+* [[Date of Birth| Date of Birth (DOB)]]
+* first [[Boarding Loc]] - start_dt and start_tm
+* first [[Service tmp entry]] - start_dt and start_tm
-*B. For existing patients at every shift, add as they become available:
+== Additional elements for [[Overstay2 Overview|Overstay]] ==
-** admit '''time'''
+Sites involved in [[Project Overstay2]] also need to add the elements required for that on admission. See [[Project Overstay2#Data required in addition to Minimal Data Set]].
-** discharge date and time (this should be entered within '''ONE week''' of discharge - this date is important for occupancy report which includes reporting the number of outstanding incomplete files.)
-** PHIN
-** DOB
-The absence of these two items in Part B, will not stop the CCMDB from sending files. These items are allowed to be empty since they may not be available initially, but they should be filled in '''as soon as available.''' '''The Discharge Date''' is most important to enter into data ASAP.
-==Instruction for STB Med Minimal Data Set - Primary Source for the Admit date/time to Medicine Service:==
+== Ideal elements ==
-*a. For Acute Care Medicine patients at STB, use the Doctors orders on the EPR as date/time accepted to Medicine Service.--[[User:TOstryzniuk|TOstryzniuk]] 17:26, 21 September 2010 (CDT)
+* [[Postal Code]] should be included if available from [[Cognos]] but is known to sometimes change during the admission; we don't expect collectors to quality check this on incomplete records
-*b. for Non Acute Care - C service medicine patients at STB, use EPR's registration tab/visit location/location history, for date/time accepted to medicine service.
+* [[Previous Location]] should be entered if easily available from Cognos data, but is not required if it requires further data review
-{{discussion}}
+== Reason why data is required for patients with [[RecordStatus]] incomplete ==
-=== Minimal data set only??===
+Data in the minimal data set is sent for all patients as soon as available, even before the patient's [[RecordStatus field]] is set to "complete". This allows us to include counts of longer-stay patients who have not yet been discharged in our statistics and reporting.
-Do these instructions apply to the minimal data set only, or to all Admit date/time entries? If so, [[Admit%2C_Transfer_and_Discharge_date_and_time#Definition_for_Medicine]] should be amended with this and it should be removed from here. [[User:Ttenbergen|Ttenbergen]] 14:40, 1 November 2010 (CDT)
-== Reason why data is required for patients that are not complete yet ==
-Data in the minimal data set is sent for all patients as soon as available, even before the patient is final checked. This allows us to include longer-stay patients who have not yet been discharged in our statistics and reporting.
 Data from patients who are not yet complete is used for the following:
 * to generate occupancy statistics
-* to be able to finalize temporary studies before long-stay patients are eventually discharged
 * to monitor the number of outstanding patients
+Minimal dataset information can be used for reporting; we will include a caveat that it is preliminary and not yet quality checked. We will not do additional [[cross check]]s to validate minimal dataset data on incomplete records. <!-- 2022-08-03 JALT decision -->
+{{Data Integrity Check List}}
+== Related articles ==
+{{Related Articles}}
-[[Category: Data Collection Guide]]
+[[Category:Registry Data| *]]
-[[Category: IT Instructions]]
+[[Category:Data Collection Guide]]
+[[Category:2016 Time and Place changes]]