STB Electronic Patient Record: Difference between revisions

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See [[EPR Gateway]] for regional access to EPR used by all collectors.
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 ==
== Implementation Status ==
All sites are at different stages of EPR implementation. Please list what is included at your site here:
All sites are at different stages of EPR implementation. It is fully implemented at STB.
* fully implemented at STB
 
=== 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
* Physician orders
* laboratory  
* laboratory  
* pharmacy data (MAR)
* pharmacy data (MAR)
* admit and discharge times under patient registration
* 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
* integrated progress notes
* nurses operative report
 
* physicians OR notes
*As of Sept, 2017, all chart information is found in the Electronic Patient Record for MICU except:  The ICU nurses flow sheets, Echo reports, blood product sheets.  (These items are still part of the paper chart). 
* Central line insertions
*As of September, 2017, the nurses operative report is in EPR under documents.  The physicians OR notes have been in EPR for some time.  Central line insertions are put in EPR under documents, endoscopy has a paper version and an EPR version.  The heart cath has both paper and EPR versions of the report. ER is mostly all EPR now.  The only exclusive paper reports are echo reports and the anesthesia record.  Other paper elements include blood product sheets, nurses flow sheets, intake and output sheets, CRRT sheets & GCS sheets.--[[User:LKolesar|LKolesar]] 12:40, 2017 September 7 (CDT)
* diagnostic imaging, including echocardiograms
* Cardiac Catheterization reports; access results via link to the right of the document


=== data still recorded outside of EPR ===
=== Data documented in paper and EPR ===
* We still access time of icu admission, continuous medication infusions and vital signs for apache from icu flowsheets, and check amount of blood products delivered from the blood transfusion record sheet, and TEE reports for patients having OHS.
* endoscopy has a paper version and an EPR version. 
* heart cath has both paper and EPR versions of the report.  


== See also ==
=== Data still recorded only outside of EPR / on paper ===
* [[EPR Lists]]
* continuous medication infusions
* 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 (Medicine)]]

Latest revision as of 11:07, 1 March 2024

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. It is fully implemented at STB.

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

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

  • continuous medication infusions
  • 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: