STB MICU Collection Guide: Difference between revisions
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== Process of data collection== | == Process of data collection== | ||
* | * The main paper charts are kept at the individual bedsides as well. | ||
* see below for information on which items are in the paper chart. | * see below for information on which items are in the paper chart. | ||
* | *There may also be ward follow ups. Patients from MICU can be transferred to almost any ward in the hospital (surgical wards are 4AS and 4ASstepdown; 7AS and 7AW, 2B); (acute medical wards are E5, E6); (chronic medicine wards are B5, A6S, E4); (Gyne is A6W); (Cardiology ward is A5S); (Palliative ward is A8W); (Psychiatry is McEwen). (Obstetrics is on the 3rd floor includes L&D, postpartum and LDRP); (CR4 is the cardiac surgery inpatient unit in Asper building). | ||
*Patients that have been discharged will need to have their charts reviewed in Medical Records so this list must be put down and it usually takes 2 days or so to obtain the charts if they are available. | *Patients that have been discharged will need to have their charts reviewed in Medical Records so this list must be put down and it usually takes 2 days or so to obtain the charts if they are available. | ||
*Once all the paper components have been reviewed and the profiles updated with this information, the data collector can read the EPR information in the Data Office (N4069). EPR contains all physician orders, labs, DI results, MAR, Pt information like address, etc. and all progress notes. | *Once all the paper components have been reviewed and the profiles updated with this information, the data collector can read the EPR information in the Data Office (N4069). EPR contains all physician orders, labs, DI results, MAR, Pt information like address, etc. and all progress notes. | ||
Revision as of 14:17, 2021 February 12
This article contains collection information specific to the STB_MICU/SICU at St Boniface. STB MICU/SICU also called ICMS, this unit includes medical, surgical and cardiac patients.
Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles.
See the following for more general information:
Unit admission log book
- The admission/discharge log book is found at the main desk near where the ward clerk usually sits.
Process of data collection
- The main paper charts are kept at the individual bedsides as well.
- see below for information on which items are in the paper chart.
*There may also be ward follow ups. Patients from MICU can be transferred to almost any ward in the hospital (surgical wards are 4AS and 4ASstepdown; 7AS and 7AW, 2B); (acute medical wards are E5, E6); (chronic medicine wards are B5, A6S, E4); (Gyne is A6W); (Cardiology ward is A5S); (Palliative ward is A8W); (Psychiatry is McEwen). (Obstetrics is on the 3rd floor includes L&D, postpartum and LDRP); (CR4 is the cardiac surgery inpatient unit in Asper building).
- Patients that have been discharged will need to have their charts reviewed in Medical Records so this list must be put down and it usually takes 2 days or so to obtain the charts if they are available.
- Once all the paper components have been reviewed and the profiles updated with this information, the data collector can read the EPR information in the Data Office (N4069). EPR contains all physician orders, labs, DI results, MAR, Pt information like address, etc. and all progress notes.
- When reviewing patients that have left the ICU, we check the TISS against the MAR and other EPR information at this time. We also do all the lab counts and Pharmacy counts. We review all of the progress notes up to the time of patient leaving the ICU. After completing all of these patient profiles, the "complete" tab is selected.
Cardiology patients
STB Cardiology service patients are collected differently than other patients, see STB Cardiac Care patients for details.
Ward contacts
Collector "base"
- Can use the extra desk space adjacent to Bed 1. You can also use individual desk space throughout the unit if there are any empty bed spots.
- I try to get a bedside table to accommodate my laptop for checking the individual patient flow sheets and tiss sheets and other parts of the paper chart. I can easily move to each individual bedside this way without utilizing the desk areas in the unit. Once I collect the information I need from the bedside paper charts then I read the rest of the charts in the office on EPR and enter this information utilizing Extended desktop external split screens.--LKolesar 18:03, 2015 August 18 (CDT)
Location of patient chart components
See STB Electronic Patient Record
The individual charts are kept at each specific bedside along with the tiss sheets. The current green sheets are kept on the rounds cart. The completed tiss and green sheets are kept in a marked binder at the main desk.
VAP / CLI worksheet
There is a sheet in the ICMS data collector's binder that has a record of VAP and line sepsis cases. This information is kept and is shared with the charge nurse and Lillian Kolley for ongoing quality control.
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Other STB ICU collection guide info
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