HSC Medicine Collection Guide

Template:Discussion HSC collector, please document collection data guidelines for related to HSC med wards here. If there are any collection details that are specific to your ward, they should be documented here also. This will serve as a reference for any collector who is assigned or choices to pick up extra hours during sick or vacation at this site.

If you want to see current guideline for sites go to: Medicine Curriculum or ICU Curriculum and look at top of this article to find link to hosp/unit specific guideline in progress.--Thanks everyone.TOstryzniuk 20:18, 21 October 2010 (CDT)

• Medicine Curriculum

wards

Medicine Database for CCMDB is collected on six medical wards at HSC including any extra HSC medicine contingency beds in other areas/wards in the hospital.

1. A4
2. B3
3. D4
4. D5
5. H4
6. H4H - HOBS - High Observation Unit (labeled by cubicles)

We collect data on all patients admitted to these wards including teaching,non-teaching and off service. For example neuro medicine patients are included. Another example renal patients under nephrology are included.

Go to: HSC Med nonteaching contingency beds

• related information moved to HSC Med nonteaching contingency beds article except for this bit because there is a discussion that needs clarification.

• If the patients are under other services (ie.neuro,oncology,rehab,etc) we DO NOT collect data on them unless they get transferred to A,D,B or H medicine ward were data is being collected?

Discussion

• HSC medicine data collectors, can you please clarify. At the beginning of this article is say that HSC medicine includes neuro, oncology and rehab patient. It says that we collect all teaching and non teaching patient to medicine wards and include neurology patient, yet for H733,(contingency beds section) it say we DO NOT include neurolgy, oncology etc patients? I highlighed in bold discrepancy above once sorted out, I will move above contingency bed information to HSC contingency bed article. thanks--TOstryzniuk 17:54, 18 January 2011 (CST)

This is correct Trish we do not collect data on neuro patients on the non-teaching units unless they have been accepted by a medicine service. The same rule would apply for another service that might get into the non-teaching unit but had not been accepted to medicine. This is not true on the wards as we collect data on everyone regardless of there teaching status, or service. Neuro and other services use beds on the ward all the time and they are included. You had asked Dr Roberts for direction on this matter of whether he wan't data on neuro patients on the non-teaching side and my understanding is the question has not been addressed.GHall 13:04, 19 January 2011 (CST)

Paper Worksheets used

• optional preference of the data collector to have paper records
• Notes can be left by double clicking on the note section, at the time of sending files delete the notes. You may need to leave notes that are relevant to that file for example a abnormally high wbc.

Daily ward Admit/transfer/discharge ward Binder

• The standard Admission / Transfer / Discharge ward Log Binder that is used and found at the main desk.Some wards write in the details other use a paper label stamped with the addressograph
• The ward also has a scribbler that usually has the names of patients admitted,discharged,transferred and moved.
• The data collector reviews the Admission Binder on each ward, assigns a serial number and enters the minimal data base for all new admissions.
• The admission and discharge "times" are entered as per the Admission binder. Times are corrected once the chart is reviewed.

Information relevant to patients admitted to D4

• D4 is a ward that accepts both medical and surgical patients.

Area specific data collection practices exist that will be written in the near future by Fran Lindell

• D4 admits Renal Transplants and Renal Donors. These pts are marked surgical. Renal Tx's are usually admitted from home.The admit time is that registered on the admission sheet.

They're admit Dx is pre-op optimization. Their first comp is Renal Tx ( choose living or cadaveric) If the pt was on HD dialysis, they may or maynot have have a HD prior to surgery. Mark task, no HD or chronic HD, as it applies. If they require HD after their renal Tx, this becomes acute HD task. Because chronic task & acute task cannot be marked at the same time, it is more important to capture the acute HD task. Peritoneal dialysis pt's always have dialsate instilled night before and drained prior to Sx. Same rule applies, capture chronic PD task, unless pt required acute PD post renal Tx. N.B. Since CRF is in co-morb, ARF will not be accepted in comp Dx when file is completed and sent. The complication is either ATN or Renal Tx problem (ie in case of delayed graft function) Renal donors are admitted from HSC Recovery.Admit Dx is Nephrectomy - donor. Sometimes surgeon chooses to do renal Bx at same time. Initial VS are taken from last entry on PACU record. The tasks for both pts are how independent they were prior to hospitalization.--FLindell 16:16, 17 December 2010 (CST)

Information relevant to patients admitted to B3

• B3 is both a medicine, and surgical unit.There is no B medicine service. The unit is split into two, ten beds to medicine, the rest to day surgery.

There is a white board opposite the main desk and the inpatients (which are medicine) are written in Black. Cathy is the unit clerk and is more then willing to help any new comer out. Space is very limited on B3 log book is kept at the desk--PStein 12:07, 6 December 2010 (CST)

Medical Records

• requests are written then may be faxed to Lorna at 75002,it could take a few days to receive or a print out of the MR list can be hand delivered to Lorna and placed in her incoming mailbox.
• charts requested before 1400 hrs will be pulled by MR staff overnight and be available next day is the general rule of thumb.

Technical Support

• If you are having problems with the laptops you need to call the Technical Support.