Notes field

Data Element (edit)
Field Name:	Notes
CCMDB Label:	Notes
CCMDB tab:	Top Row
Table:	L_Log
Data type:	memo
Length:	not stated
Program:	Med and CC
Created/Raw:	Raw
Start Date:	1988-07-11
End Date:	2300-01-01
Sort Index:	9

Used by data collectors to keep notes during collection.

• SMW

Legacy implementation right in the table

• Cargo

• Categories

• Forms

The notes field expands to a bigger form when you double-click on it.

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 collection practices which result in problems during vacation coverage or on shared wards.

• we do not want collector to write copious history notes from charts into this note section. Not necessary and not required.

Patients being sent

• Template:Discussion perhaps tagging things for main office, as indicated below, should be done differently as notes are difficult to sift through in main office. Some collectors delete notes before they send. Others put no notes. People use non standard abbreviation or own codes which is not clear for main office.
• For patients you are ready to send, 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:
  • extreme physiological APACHE values, eg Sys BP of 50 valid , see APACHE_Scoring_table and APACHE_physiological_variable_collection#Exceptionally_high_or_low_values
  • tasks for renal transplant patients that do not follow the norm

Up-to where/when collection is complete

• STB - where we have left off reading in the EPR notes by entering the date/time last read

Diagnoses or other data that 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
  • Template:Discussion should such a dx be entered and noted in notes, or not entered until confirmed and tracked in notes instead? Ttenbergen 16:26, 9 November 2010 (CST)
    • this is probably a question for main office, especially now that they use the data before completion. Ttenbergen 14:24, 2014 September 19 (CDT)
    • if data is INCOMPLETE, main does not rely on DX info. If DX has not been confirmed, notes field is good place to put not to self or to collector covering.Trish Ostryzniuk 17:26, 2017 November 20 (CST)

Supplemental data

• track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.
  • would you not just enter a new line for these, and the date of the new line would tell you how far you got? Ttenbergen 14:24, 2014 September 19 (CDT)

• to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
  • Template:Discussion only useful if we review it as that at main office. most of the dx use there is by filter, so they would never see this. main office: thoughts? Ttenbergen 14:24, 2014 September 19 (CDT)
    • we don't look at this in notes. Trish Ostryzniuk 17:26, 2017 November 20 (CST)

• to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.

• • useful how? Ttenbergen 14:24, 2014 September 19 (CDT)
    • Baseline Creatinine is helpful because to code acute renal insufficiency, the Creatinine must be 100 points over the baseline. I also use it for sorting out criteria for VAP's and Septic Shock tmp stuff before entering it. I will usually delete this once I have it sorted out. --LKolesar 12:17, 2017 May 4 (CDT)
      • We have a spot in Apache for creatinine, but it's hidden for Med. The field is still there, though. If we are entereing this on a regular basis, should we enter it there rather than in the free text notes field? Ttenbergen 16:27, 2017 November 20 (CST)

• to define what exactly needs to be entered, when a profile is only partially completed.