STB Medicine Collection Guide: Difference between revisions

Line 2:

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.

*We are currently in phase 2 of electronic patient record (EPR) implementation. All patient log data, location information, lab, and diagnosis imaging results, tests, physicians' orders and pharmacy are obtained electronically.

*We are currently in phase 2 of electronic patient record [[EPR]] implementation. All patient log data, location information, lab, and diagnosis imaging results, tests, physicians' orders and pharmacy are obtained electronically.

Contact Trish for information re: application/security clearance forms and orientation to EPR.

Contact Trish for information re: application/security clearance forms and orientation to [[EPR]].

Until EPR access/orientation completed, use the Wards' daily admit/transfer/discharge binder for the Ward date/time of event. If no time marked in, refer to the nurses notes in the charts Integrated Progress Notes. The admit/transfer/discharge binders are located at the main desk on the wards. On E6, the binder is kept between the CRN and the Ward Clerk. On 5B, it is on top of the desk ledge, to the left of the CRN.

Until EPR access/orientation completed, use the Wards' daily admit/transfer/discharge binder for the Ward date/time of event. If no time marked in, refer to the nurses notes in the charts Integrated Progress Notes. The admit/transfer/discharge binders are located at the main desk on the wards. On E6, the binder is kept between the CRN (Clinical Resource Nurse) and the Ward Clerk. On 5B, it is on top of the desk ledge, to the left of the CRN.

For accepted to Medicine date/time (i.e. the admit date and time), FOR THOSE PATIENTS ADMITTED FROM E.R: use the date and time from the "accepted to service" on the ~~epr~~ orders. i.e. in the epr, click on orders, then highlight the order that says "admit to inpatient-medicine-medical service". Right click on that order. Scroll down to history, then across to status. Click on status. Use the date and time as listed in the top "new" order. This is the date and time the patient is accepted to medical service. FOR THOSE PATIENTS ADMITTED FROM ANOTHER WARD: use the date and time plus five minutes from the discharge date and time of the sending ward. [[User:DPageNewton|DPageNewton]] 15:17, 20 June 2011 (CDT)

For accepted to Medicine date/time (i.e. the admit date and time),

*FOR THOSE PATIENTS ADMITTED FROM E.R: use the date and time from the "accepted to service" on the [[EPR]] orders. i.e. in the epr, click on orders, then highlight the order that says "admit to inpatient-medicine-medical service". Right click on that order. Scroll down to history, then across to status. Click on status. Use the date and time as listed in the top "new" order. This is the date and time the patient is accepted to medical service.

*FOR THOSE PATIENTS ADMITTED FROM ANOTHER WARD: use the date and time plus five minutes from the discharge date and time of the sending ward. [[User:DPageNewton|DPageNewton]] 15:17, 20 June 2011 (CDT)

Hard copies of the Lab results will be on the chart within 24 hours of admission, if not much sooner.

@@ Line 2: / Line 2: @@
 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.
-*We are currently in phase 2 of electronic patient record (EPR) implementation. All patient log data, location information, lab, and diagnosis imaging results, tests, physicians' orders and pharmacy are obtained electronically.
+*We are currently in phase 2 of electronic patient record [[EPR]] implementation. All patient log data, location information, lab, and diagnosis imaging results, tests, physicians' orders and pharmacy are obtained electronically.
-Contact Trish for information re: application/security clearance forms and orientation to EPR.
+Contact Trish for information re: application/security clearance forms and orientation to [[EPR]].
-Until EPR access/orientation completed, use the Wards' daily admit/transfer/discharge binder for the Ward date/time of event. If no time marked in, refer to the nurses notes in the charts Integrated Progress Notes. The admit/transfer/discharge binders are located at the main desk on the wards. On E6, the binder is kept between the CRN and the Ward Clerk. On 5B, it is on top of the desk ledge, to the left of the CRN.
+Until EPR access/orientation completed, use the Wards' daily admit/transfer/discharge binder for the Ward date/time of event. If no time marked in, refer to the nurses notes in the charts Integrated Progress Notes. The admit/transfer/discharge binders are located at the main desk on the wards. On E6, the binder is kept between the CRN (Clinical Resource Nurse) and the Ward Clerk. On 5B, it is on top of the desk ledge, to the left of the CRN.
-For accepted to Medicine date/time (i.e. the admit date and time), FOR THOSE PATIENTS ADMITTED FROM E.R: use the date and time from the "accepted to service" on the epr orders. i.e. in the epr, click on orders, then highlight the order that says "admit to inpatient-medicine-medical service". Right click on that order. Scroll down to history, then across to status. Click on status. Use the date and time as listed in the top "new" order. This is the date and time the patient is accepted to medical service. FOR THOSE PATIENTS ADMITTED FROM ANOTHER WARD: use the date and time plus five minutes from the discharge date and time of the sending ward. [[User:DPageNewton|DPageNewton]] 15:17, 20 June 2011 (CDT)
+For accepted to Medicine date/time (i.e. the admit date and time),
+*FOR THOSE PATIENTS ADMITTED FROM E.R: use the date and time from the "accepted to service" on the [[EPR]] orders. i.e. in the epr, click on orders, then highlight the order that says "admit to inpatient-medicine-medical service". Right click on that order. Scroll down to history, then across to status. Click on status. Use the date and time as listed in the top "new" order. This is the date and time the patient is accepted to medical service.
+*FOR THOSE PATIENTS ADMITTED FROM ANOTHER WARD: use the date and time plus five minutes from the discharge date and time of the sending ward. [[User:DPageNewton|DPageNewton]] 15:17, 20 June 2011 (CDT)
 Hard copies of the Lab results will be on the chart within 24 hours of admission, if not much sooner.