Notes field: Difference between revisions
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* to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them. | * to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them. | ||
** {{discussion}} only useful if we review it as that at main office. most of the dx use there is by filter, so they would never see this. main office: thoughts? Ttenbergen 14:24, 2014 September 19 (CDT) | ** {{discussion}} only useful if we review it as that at main office. most of the dx use there is by filter, so they would never see this. main office: thoughts? Ttenbergen 14:24, 2014 September 19 (CDT) | ||
* to enter info on base creatinine, bmi, or other tidbits of info that are useful to know. | * to enter info on base creatinine, bmi, or other tidbits of info that are useful to know. | ||
Revision as of 11:45, 2018 October 26
| 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.
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.
- 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
- Template:Discussion perhaps tagging things for main office, as indicated below, should be done differently or in different place as notes are difficult to sift through in main office. Some collectors delete notes before they send. Others put no notes. People use non standard abbreviation or own codes which is not clear for main office.
- 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
- tasks for renal transplant patients that do not follow the norm
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
Diagnoses or other data that needs to be reviewed or checked
also to state if the diagnosis is not confirmed yet etc.
- diagnosis is still unclear as they are waiting for further tests or results
- Template:Discussion should such a dx be entered and noted in notes, or not entered until confirmed and tracked in notes instead? Ttenbergen 16:26, 9 November 2010 (CST)
- this is probably a question for main office, especially now that they use the data before completion. Ttenbergen 14:24, 2014 September 19 (CDT)
- if data is INCOMPLETE, main does not rely on DX info. If DX has not been confirmed, notes field is good place to put a Clear note to self or to collector who is covering you.Trish Ostryzniuk 17:26, 2017 November 20 (CST)
- this is probably a question for main office, especially now that they use the data before completion. Ttenbergen 14:24, 2014 September 19 (CDT)
- Template:Discussion should such a dx be entered and noted in notes, or not entered until confirmed and tracked in notes instead? Ttenbergen 16:26, 9 November 2010 (CST)
Supplemental data
- track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.
- would you not just enter a new line for these, and the date of the new line would tell you how far you got? Ttenbergen 14:24, 2014 September 19 (CDT)
- to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
- Template:Discussion only useful if we review it as that at main office. most of the dx use there is by filter, so they would never see this. main office: thoughts? Ttenbergen 14:24, 2014 September 19 (CDT)
- to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.
- useful how? Ttenbergen 14:24, 2014 September 19 (CDT)
- Baseline Creatinine is helpful because to code acute renal insufficiency, the Creatinine must be 100 points over the baseline. I also use it for sorting out criteria for VAP's and Septic Shock tmp stuff before entering it. I will usually delete this once I have it sorted out. --LKolesar 12:17, 2017 May 4 (CDT)
- We have a spot in Apache for creatinine, but it's hidden for Med. The field is still there, though. If we are entereing this on a regular basis, should we enter it there rather than in the free text notes field? Ttenbergen 16:27, 2017 November 20 (CST)
- Baseline Creatinine is helpful because to code acute renal insufficiency, the Creatinine must be 100 points over the baseline. I also use it for sorting out criteria for VAP's and Septic Shock tmp stuff before entering it. I will usually delete this once I have it sorted out. --LKolesar 12:17, 2017 May 4 (CDT)
- useful how? Ttenbergen 14:24, 2014 September 19 (CDT)
- to define what exactly needs to be entered, when a profile is only partially completed.