STB MICU Collection Guide: Difference between revisions

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== ~~duplicate info moved here from [[STB MICU]]]~~==

== Process of data collection==

~~'' this needs to be integrated better in this article, but best done by someone who actually collects there ''~~

* Each day the data collector must go to each bedside to obtain data from the nurses' flow sheets which are still in paper format. At this time the tiss sheets which are kept on the bedside chart can be checked to ensure accuracy. Apache vital signs must be obtained from the paper flow sheets. The main paper charts are kept at the individual bedsides as well. It is helpful to view the operative records, angiogram records, endoscopy reports, code blue records, notes sent from other hospitals, etc. at this time.

*There is a log book at the main desk which the admissions and discharges are entered each day. These can also be seen in EPR. There is a purple binder at the main desk where completed tiss and green sheets are left for the data collector. The ongoing green sheets are kept in a binder on the rounds cart. Each day the data collector must go to each bedside to obtain data from the nurses' flow sheets which are still in paper format. At this time the tiss sheets which are kept on the bedside chart can be checked to ensure accuracy. Apache vital signs must be obtained from the paper flow sheets. The main paper charts are kept at the individual bedsides as well. It is helpful to view the operative records, angiogram records, endoscopy reports, code blue records, notes sent from other hospitals, etc. at this time.

*Once the bedside chart information has been collected and entered on the laptop, there may 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).

*Once the bedside chart information has been collected and entered on the laptop, there may 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.

*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. The completed profiles need to be sent before 1030 am.

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-== duplicate info moved here from [[STB MICU]]]==
+== Process of data collection==
- '' this needs to be integrated better in this article, but best done by someone who actually collects there ''
+* Each day the data collector must go to each bedside to obtain data from the nurses' flow sheets which are still in paper format. At this time the tiss sheets which are kept on the bedside chart can be checked to ensure accuracy. Apache vital signs must be obtained from the paper flow sheets.   The main paper charts are kept at the individual bedsides as well.  It is helpful to view the operative records, angiogram records, endoscopy reports, code blue records, notes sent from other hospitals, etc.  at this time.
-*There is a log book at the main desk which the admissions and discharges are entered each day.  These can also be seen in EPR.  There is a purple binder at the main desk where completed tiss and green sheets are left for the data collector.  The ongoing green sheets are kept in a binder on the rounds cart. Each day the data collector must go to each bedside to obtain data from the nurses' flow sheets which are still in paper format. At this time the tiss sheets which are kept on the bedside chart can be checked to ensure accuracy. Apache vital signs must be obtained from the paper flow sheets.   The main paper charts are kept at the individual bedsides as well.  It is helpful to view the operative records, angiogram records, endoscopy reports, code blue records, notes sent from other hospitals, etc.  at this time.
+*Once the bedside chart information has been collected and entered on the laptop, there may 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).
-*Once the bedside chart information has been collected and entered on the laptop, there may 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.
+*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.  The completed profiles need to be sent before 1030 am.