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| == Collection instructions == | | == Collection instructions == |
| | <!--As discussed [[Task_Team_Meeting_-_Rolling_Agenda_and_Minutes#ICU_Database_Task_Group_Meeting_.E2.80.93_October_31.2C_2018]] --> |
| | *We code CCI procedures in 5 different collection modes''': |
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| === Determining if the procedure you found is one we collect ===
| | {{:CCI collect each}} |
| *There are THREE subsets of procedures we '''will'' code
| | {{:CCI collect count each}} |
| **Procedures done outside the unit
| | {{:CCI collect count days}} |
| **Procedures done on the unit including an endoscope
| | {{:CCI collect count units}} |
| **A select group of other procedures done on the unit.
| | {{:CCI collect first}} |
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| ==== (A) Procedures done outside the unit ==== | | === List of CCI Elements and their collection modes === |
| Include ''all '''[[List of CCI procedures we don't code|codable]]''' procedures'' that meet the definition of one of the [[Px Type]]s that are done '''outside the patient’s unit'''.
| | {{Collapsable |
| | | always= picklist |
| | | full= |
| | {{#ask: [[Has CCI Picklist Code::+]][[Has StopDate::>{{CURRENTDAY}} {{CURRENTMONTHNAME}} {{CURRENTYEAR}}]] |
| | |?Has CCI Collection Mode |
| | |format=broadtable |
| | |link=all |
| | |limit=1000 |
| | |class=sortable wikitable smwtable |
| | }} }} |
| | {{Collapsable |
| | | always= component 2 list |
| | | full= |
| | {{#ask: [[Has CCI 2 Code::+]][[Has StopDate::>{{CURRENTDAY}} {{CURRENTMONTHNAME}} {{CURRENTYEAR}}]] |
| | |?Has CCI Collection Mode |
| | |format=broadtable |
| | |link=all |
| | |limit=1000 |
| | |class=sortable wikitable smwtable |
| | }} }} |
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| ==== (B) Procedures done on the unit (endoscope or non-therapeutic) ==== | | === Selecting and entering [[CCI]] procedure in [[CCMDB]] === |
| *This includes both diagnostic and therapeutic procedures done with an endoscope -- and that scope may be inserted through an oriface, incision or wound.
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| *Includes '''all of the following '''[[List of CCI procedures we don't code|codable]]''' procedures''' done on the unit:
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| === (C) Other on-unit procedures ===
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| *(b) all [[List of CCI procedures we don't code|codable]] '''[[Diagnostic Px]]s'''
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| *(c) all [[List of CCI procedures we don't code|codable]] '''[[Imaging Px]]s'''
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| *(d) all [[List of CCI procedures we don't code|codable]] '''[[Obstetric Px]]s'''
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| *(d) all [[List of CCI procedures we don't code|codable]] '''[[Misc Px]]s'''
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| ==== [[CCI Procedures coded once per ward admission]] ====
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| Some procedures are only coded the first time they happen. See [[CCI Procedures coded once per ward admission]].
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| === Don't code sub-procedures that are part of a larger procedure ===
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| Do not code a procedure that is part of a "Bigger" procedure already coded.
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| '''Example:''' In the course of many or most CABG surgeries, there is placement of chest tubes, pacer wires, and vein harvest, but do NOT code those procedures separately, since they are "included" in the CABG code.
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| === Before You Decide to NOT Code a Procedure ===
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| *We're not looking to code procedures that not either: (a) on the picklist, or (b) able to be constructed from it's components [e.g. a body part, and what was done to that body part].
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| *The main issue here is that among the lists "what was done", we haven't included EVERY possibility.
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| **For example, in the Imaging Procedures, besides some plain X-rays contained in that picklist, the "what type of imaging study was done" does NOT include plain x-rays. Thus we're not enabling creation of a plain X-ray of other body part other than those contained in the picklist.
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| **Similarly, for the Therapeutic Procedures, there is a list of approximately 30 items of "what was done" to the chosen body part. So some items of "what was done" are not available and you won't be able to code such procedures.
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| ***'''BUT, before you decide this is the case, you will need to become very familiar with the descriptions of EACH of the "what was done" items that ARE available'''. For example the item '''[[Bypass]]''' includes creating a ostomy (which includes a colostomy and even a tracheostomy).
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| ****See '''[[CCI component 2 codes - what was done]]'''
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| === [[Aborted Procedure]] ===
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| *See [[Aborted Procedure]] for how to code
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| == Selecting and entering [[CCI]] procedure in [[CCMDB]] == | |
| Follow these steps, in this order: | | Follow these steps, in this order: |
| # for every procedure: | | # for every procedure: |
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| ### enter a [[Px_Count]] - the number of '''separate''' times it was done''' '''''on a given day | | ### enter a [[Px_Count]] - the number of '''separate''' times it was done''' '''''on a given day |
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| === Repeated procedures === | | === No Procedures Performed === |
| If a procedure is done repeatedly '''on the same day''', only enter it once but count it in [[Px_Count]]. | | If no procedures were performed '''enter [[No procedure performed]] as an [[Admit Procedure]] with a [[Px Count]] of 1 into the [[CCI Picklist]]''', the top of the tab. Do not enter any procedrues into the CCI Component section, ie leave it as "[[No procedure entered]]". Entering this will mean at least one CCI entry is present when [[Query check CCI must have entry]] checks that entering procedures was not just forgotten. |
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| | === We are not tracking all possible procedures === |
| | We are not tracking all possible procedures; see [[Reasoning around moving to CCI and our subset of it#Why do we not include the entire set of CCI codes]] and [[List of CCI procedures we don't code]] for more info. |
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| | === Before You Decide to NOT Code a Procedure / Procedures not coded=== |
| | We did not include all possible CCI codes. If a procedure can not be coded using the picklist or combined method, then we likely are not interested in coding it. See [[List of CCI procedures we don't code]] for procedures we explicitly don't collect. If you come across a procedure you were not able to code, but think we probably should be coding, please note it [[List of CCI procedures we don't code|there]]. |
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| Procedures done on a '''different''' day should be entered again with a different date. This should be really quick by using the "duplicate" button.
| | === Don't code sub-procedures that are part of a larger procedure === |
| | Do not code a procedure that is part of a "Bigger" procedure already coded. |
| | '''Example:''' In the course of many or most CABG surgeries, there is placement of chest tubes, pacer wires, and vein harvest, but do NOT code those procedures separately, since they are "included" in the CABG code. {{DT|I think this is changing as per task}} |
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| === Related Imaging, Diagnostic and Therapeutic procedures performed at the same time === | | === Related Imaging, Diagnostic and Therapeutic procedures performed at the same time === |
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| * If a CT is done on the abdomen, chest and pelvis, enter 3 entries in the component area? | | * If a CT is done on the abdomen, chest and pelvis, enter 3 entries in the component area? |
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| === We are not tracking all possible procedures === | | === [[Aborted Procedure]] === |
| We are not tracking all possible procedures; see [[Reasoning around moving to CCI and our subset of it#Why do we not include the entire set of CCI codes]] and [[List of CCI procedures we don't code]] for more info.
| | *See [[Aborted Procedure]] for how to code |
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| {{Discuss | who = Tina | question =
| | === Repeated procedures === |
| *How do we put the procedure: thrombectomy of the femoral artery for a blocked vascular graft (axillo-femoral graft). Please advise. --[[User:LKolesar|LKolesar]] 13:14, 2018 December 11
| | If a procedure is done repeatedly '''on the same day''', only enter it once but count it in [[Px_Count]]. |
| *AG REPLY --- in general it appears that procedures performed on vascular grafts (either synthetic grafts or vessels harvested from elsewhere for use) are coded just as you would if the same thing was done to the native vessel. So this would be 1.KG.57 = therapeutic EXTACTION procedure [which includes thrombectomy] on arteries of the leg NOS [which includes the femoral arteries]
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| *Related item from AG: We should put this general rule about CCI someplace --- I'm not sure where, Tina??}}
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| === No Procedures Performed ===
| | Procedures done on a '''different''' day should be entered again with a different date. This should be really quick by using the "duplicate" button. |
| If no procedures were performed '''enter [[No procedure performed]] as an [[Admit Procedure]] with a [[Px Count]] of 1 into the [[CCI Picklist]]''', the top of the tab. Do not enter any procedrues into the CCI Component section, ie leave it as "[[No procedure entered]]". Entering this will mean at least one CCI entry is present when [[Query check CCI must have entry]] checks that entering procedures was not just forgotten.
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| === Procedures not coded ===
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| See [[List of CCI procedures we don't code]]
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| == Proposed tweak ==
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| As discussed [[Task_Team_Meeting_-_Rolling_Agenda_and_Minutes#ICU_Database_Task_Group_Meeting_.E2.80.93_October_31.2C_2018]]:
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| *After discussion we '''recognized that we will need to create machinery to code 3 different categories of such procedures''':
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| **(i) Those coded every time they occur -- recorded with dates. Example is EGD
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| **(ii) Those for which we mainly want total counts -- record the first date in which done, plus the total count over the entire admission. Example is CXR, ABG. For this one there is needed software/data entry “machinery” that Tina/Trish/etc will talk about offline.
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| **(iii) Those for which we would ‘’prefer’’ the # of days on which it was done. Examples are noninvasive mechanical ventilation, dialysis, ECMO. However, after discussion we decided that in order to reduce the workload on the data collectors, we will only collect the date of the first use. We could reconsider adding # of days for these at a later point in time.
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| {{Discuss | who = All | question =
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| * Thoughts? }}
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| ----
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| {{:CCI collect each}}
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| {{:CCI collect count each}}
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| {{:CCI collect count days}}
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| {{:CCI collect count units}}
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| {{:CCI collect first}}
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| === List of CCI Elements and how they are collected ===
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| {{Collapsable
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| | always= picklist
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| | full=
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| {{#ask: [[Has CCI Picklist Code::+]][[Has StopDate::>{{CURRENTDAY}} {{CURRENTMONTHNAME}} {{CURRENTYEAR}}]]
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| |?Has CCI Collection Mode
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| |format=broadtable
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| |link=all
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| |limit=1000
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| |class=sortable wikitable smwtable
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| }} }}
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| {{Collapsable
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| | always= component 2 list
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| | full=
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| {{#ask: [[Has CCI 2 Code::+]][[Has StopDate::>{{CURRENTDAY}} {{CURRENTMONTHNAME}} {{CURRENTYEAR}}]]
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| |?Has CCI Collection Mode
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| |format=broadtable
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| |link=all
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| |limit=1000
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| |class=sortable wikitable smwtable
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| }} }}
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| ==Data Integrity Checks == | | ==Data Integrity Checks == |