STB Electronic Patient Record: Difference between revisions

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~~'''~~EPR~~''' -'''E'''lectronic''' P'''atient '''R'''ecord~~

This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]].

*also referred to ~~as '''EHR''' - '''E'''lectronic '''H'''ealth ''' R'''ecord~~

~~Used to collect the laboratory~~ and ~~pharmacy data~~. As ~~well it records admit and discharge times under patient registration~~.

== 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. '''

~~Currently~~ only at ~~the '''ST Boniface Hospital'''~~

=== Data only documented in EPR ===

*What is EHR?- ~~[http://www.manitoba~~-~~ehealth.ca/news.html EHR News]~~

* data listed at [[EPR#Data in EPR]]

**~~Phase 1 of~~ EPR ~~which includes patient registration~~ information, ~~labs~~, ~~some patient information~~, ~~billing information started April 12, 2007~~

**~~Phase 2A includes order entry~~, ~~order management and medication worksheet for nurse documentation (MAR) was implemented between December 2008~~ to ~~February 2009.~~

* Physician orders

**ClinDoc: implementation dates: Nov 2012 STB MICU, CCU, CICU. Jan 2013 STB Med wards.

* laboratory

== ~~Implementation Status~~ ==

* pharmacy data (MAR)

~~We are in phase 2 of electronic patient record implementation~~. ~~This means that all patient log data, location information, lab~~ and ~~diagnosis imaging results, tests, physicians’ orders and pharmacy are obtained electronically~~. ~~Eventually all data will be obtained electronically.~~

* 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.

== ~~Clindoc~~ ==

=== Data still recorded only outside of EPR / on paper ===

~~This is the next Phase of EPR at STB that include electronic clinical notes.~~

* vital signs for apache from icu flowsheets,

*~~CICU & CCU - Starting end~~ of ~~November 2012~~

* amount of blood products delivered from the blood transfusion record sheet

*~~Medicine/MICU/SICU - current plan start sometime January 2013~~

* anesthesia record

*~~1-1.5 hr The eLearning option is available~~ on the ~~Manitoba eHealth Learning Management System~~ (~~LMS~~) ~~and is available to all WRHA staff with WRHA or site based email accounts~~. ~~STB Data Collector will have to complete online learning. Email sent today with instruction how to log in~~ and ~~create account for LMS.-[[User:TOstryzniuk|Trish Ostryzniuk]] 21:53, 2012 November 21 (EST)~~

* 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

== ~~eHealth System Access~~ ==

== Related articles ==

* [http://services.manitoba-ehealth.ca/acctManagement.html ehealth Forms]

* eHealth needs to be informed of any new or replacement computer that needs to access the EPR, it needs to be added to a list. An email to the service desk with the PC name should do the trick

[[Category:St Boniface Hospital Office (Medicine)]]

@@ Line 1: / Line 1: @@
-'''EPR''' -'''E'''lectronic''' P'''atient '''R'''ecord
+This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see [[EPR]].
-*also referred to as '''EHR''' - '''E'''lectronic '''H'''ealth ''' R'''ecord
-Used to collect the laboratory and pharmacy data. As well it records admit and discharge times under patient registration.
+== 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. '''
-Currently only at the '''ST Boniface Hospital'''
+=== Data only documented in EPR ===
-*What is EHR?- [http://www.manitoba-ehealth.ca/news.html EHR News]
+* data listed at [[EPR#Data in EPR]]
-**Phase 1 of EPR which includes patient registration information, labs, some patient information, billing information started April 12, 2007
+<!-- anything else? Only list here if not already documented in general -->
-**Phase 2A includes order entry, order management and medication worksheet for nurse documentation (MAR) was implemented between December 2008 to February 2009.
+* Physician orders
-**ClinDoc: implementation dates:  Nov 2012 STB MICU, CCU, CICU.  Jan 2013 STB Med wards.
+* laboratory
-== Implementation Status ==
+* pharmacy data (MAR)
-We are in phase 2 of electronic patient record implementation.  This means that all patient log data, location information, lab and diagnosis imaging results, tests, physicians’ orders and pharmacy are obtained electronically.  Eventually all data will be obtained electronically.
+* 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.
-== Clindoc ==
+=== Data still recorded only outside of EPR / on paper ===
-This is the next Phase of EPR at STB that include electronic clinical notes.
+* vital signs for apache from icu flowsheets,
-*CICU & CCU - Starting end of November 2012
+* amount of blood products delivered from the blood transfusion record sheet
-*Medicine/MICU/SICU - current plan start sometime January 2013
+* anesthesia record
-*1-1.5 hr The eLearning option is available on the Manitoba eHealth Learning Management System (LMS) and is available to all WRHA staff with WRHA or site based email accounts. STB Data Collector will have to complete online learning.  Email sent today with instruction how to log in and create account for LMS.-[[User:TOstryzniuk|Trish Ostryzniuk]] 21:53, 2012 November 21 (EST)
+* 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
-== eHealth System Access ==
+== Related articles ==
-* [http://services.manitoba-ehealth.ca/acctManagement.html  ehealth Forms]
+{{Related Articles}}
-* eHealth needs to be informed of any new or replacement computer that needs to access the EPR, it needs to be added to a list. An email to the service desk with the PC name should do the trick
 [[Category:St Boniface Hospital Office (Medicine)]]