STB Electronic Patient Record: Difference between revisions
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Ttenbergen (talk | contribs) m moved here from STB_MICU_Collection_Guide so it's only in one place. |
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* admit and discharge times under patient registration | * admit and discharge times under patient registration | ||
* integrated progress notes | * integrated progress notes | ||
*As of January, 2013, all chart information is found in the Electronic Patient Record for MICU except: The nurses flow sheets, OR records, ER records, Echo Reports, Endoscopy reports, heart cath. reports, central line insertion sheets, blood product sheets. (These items are still part of the paper chart). --[[User:LKolesar|LKolesar]] 11:42, 2013 May 6 (EDT) | |||
*As of September, 2017, the nurses operative report is in EPR under documents. The physicians OR notes have been in EPR for some time. Central line insertions are put in EPR under documents, endoscopy has a paper version and an EPR version. The heart cath has both paper and EPR versions of the report. ER is mostly all EPR now. The only exclusive paper reports are echo reports and the anesthesia record. Other paper elements include blood product sheets, nurses flow sheets, intake and output sheets, CRRT sheets & GCS sheets.--[[User:LKolesar|LKolesar]] 12:40, 2017 September 7 (CDT) | |||
=== data still recorded outside of EPR === | === data still recorded outside of EPR === | ||
Revision as of 14:25, 12 September 2017
See EPR Gateway for regional access to EPR used by all collectors.
Implementation Status
All sites are at different stages of EPR implementation. Please list what is included at your site here:
- fully implemented at STB
- Physician orders
- laboratory
- pharmacy data (MAR)
- admit and discharge times under patient registration
- integrated progress notes
- As of January, 2013, all chart information is found in the Electronic Patient Record for MICU except: The nurses flow sheets, OR records, ER records, Echo Reports, Endoscopy reports, heart cath. reports, central line insertion sheets, blood product sheets. (These items are still part of the paper chart). --LKolesar 11:42, 2013 May 6 (EDT)
- As of September, 2017, the nurses operative report is in EPR under documents. The physicians OR notes have been in EPR for some time. Central line insertions are put in EPR under documents, endoscopy has a paper version and an EPR version. The heart cath has both paper and EPR versions of the report. ER is mostly all EPR now. The only exclusive paper reports are echo reports and the anesthesia record. Other paper elements include blood product sheets, nurses flow sheets, intake and output sheets, CRRT sheets & GCS sheets.--LKolesar 12:40, 2017 September 7 (CDT)
data still recorded outside of EPR
- Discharge Planning Screening Tool form (DPST Form)
- We still access time of icu admission, continuous medication infusions and vital signs for apache from icu flowsheets, and check amount of blood products delivered from the blood transfusion record sheet, and TEE reports for patients having OHS.
HOW TO MAKE A BASIC VISIT LIST
- Actions tab- click on new visit list.
- Your role tab-leave blank
- Location tab-click on "include pts at selected locations only"
- Then, double click on specific hospital
- Then, click on "inpatient"
- Then, click on the specific ward or icu desired for the list
- Then, click "add".
- Then, OK
- Then, a pop up will ask what name you want to give your new list, you type in the name ie MICU.
- Then OK, should show the current list for that unit.
NOTE: Lists can be made with other criteria but these instructions are only the basic visit list for current patients.
Other possible criteria examples: discharged patients, list of patients admitted in last few days. There are too many possible options to list here. --LKolesar 12:02, 2014 October 24 (CDT)