Notes field

There is a Notes field on the laptop and in the CCMDB.mdb for every file. This field is used by data collectors to keep notes during collection. The notes field expands to a bigger form when you double-click on it.

• The contents of the notes field are not sent as part of the Output_for_TMSX_and_MedTMS and is therefore not imported into Master Critical CareTMSX or the Medicine MedTMS
• The contents of the notes field for patients with a discharge date are sent in with the PDA Status.csv (started Nov 2010)

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 collecction practices which result in problems during vacation coverage or on shared wards. We need to come to some common agreement on how the notes field is used. Template:Discussion

Patients being sent

For Final Checked patients, 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, e.g:
  • Sys BP of 50 valid
  • VRE +ve but not on isolation
  • tasks for renal transplant patients that do not follow the norm

• Pagasa, Trish, or everyone, do you have other suggestions for this? Ttenbergen 16:19, 9 November 2010 (CST)

Discharged or deceased patients not yet sent

Once you enter a discharge date or "decease" a patient the contents of the notes field will be added to the PDA Status.csv every week. This was set up to automate the requirement to explain at sending time why a patient who is discharged is not being sent. Enter the reason why sending is delayed for every patient like that. Template:Discussion

• Pagasa, Trish, or everyone, do you have other suggestions for this? Ttenbergen 16:19, 9 November 2010 (CST)

Patients not yet discharged

Contents of the notes field for patients who do not yet have a discharge date or are set to "deceased" are not sent to the PDA Status.csv, i.e. they are for use by the collectors only. Because collectors might change over the course of a patient's stay, we still need to come to an agreement how to use this. Some common uses are as follows.

Up-to where/when collection is complete

• where we have left off

• It's interesting that you'd like to know what method I use to keep track of how far I have gotten in a chart when doing reviews, since there has been a bit of controversy just this morning from one of our doc's regarding this very issue. It has been my practice to make a small mark with a yellow highlighter in the margin of the ipn (integrated progress notes) notes, at the last note that I have read. The next time I go back to review the chart, I look for the yellow highlighter mark. I have now had two of our doc's complain about the tiny unobtrusive mark. Any other suggestions that can be used that will keep our doc's happy, would be much appreciated. Thanks. DPageNewton 17:46, 28 September 2010 (CDT)

Which data 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

Supplemental data

• track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.
• to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
• to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.
• to define what exactly needs to be entered, when a profile is only partially completed.