Notes field: Difference between revisions

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=== Patients being sent ===

*{{~~Discussion}}~~ perhaps tagging things for main office, as indicated below, should be done differently or in different place 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.

*{{Discuss| perhaps tagging things for main office, as indicated below, should be done differently or in different place 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:

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also to state if the diagnosis is not confirmed yet etc.

* diagnosis is still unclear as they are waiting for further tests or results

** {{~~discussion}}~~ should ~~such a dx~~ be entered and ~~noted in notes, or '''not''' entered until~~ confirmed ~~and tracked in notes instead?~~ [[~~User:Ttenbergen|Ttenbergen~~]] ~~16:26, 9 November 2010 (CST~~)

{{discuss|

*** this is probably a question for main office, especially now that they use the data before completion. Ttenbergen 14:24, ~~2014~~ September 19 (CDT)

*A dx should not be entered into ICD10 unless it is known and confirmed ([[ICD10_collection#.22Suspected.22_Diagnoses]]). Are collectors still entering unconfirmed dxs into ICD10 and noting so in Notes? This should not be happening... Ttenbergen 10:19, 2019 September 16 (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 a Clear note to self or to collector who is covering you.[[User:TOstryzniuk|Trish Ostryzniuk]] 17:26, 2017 November 20 (CST)

**if data is INCOMPLETE, main does not rely on DX info. If DX has not been confirmed, notes field is good place to put a Clear note to self or to collector who is covering you.[[User:TOstryzniuk|Trish Ostryzniuk]] 17:26, 2017 November 20 (CST)

***** I am not sure that is true, ~~I think Julie~~ uses the [[Primary Admit Diagnosis]] even for incomplete ~~patients~~. ~~Will flag~~ this ~~question for her.~~

*** As confirmed with Julie, Main office uses the [[Primary Admit Diagnosis]] even for incomplete records, so dx codes should not be coded for suspected dxs in ICD10. If we really want to change this, then instructions on [[ICD10_collection#.22Suspected.22_Diagnoses]] need to be made consistent with those on this page. Ttenbergen 10:19, 2019 September 16 (CDT)}}

~~{{Discuss | who = Julie | question = * Do you use diagnosis information before patients are complete~~, e.g. ~~[[Primary Admit Diagnosis~~]]?

~~Yes, I use the primary diagnosis for the reason of readmission even if the record status is incomplete~~. ~~--[[User~~:~~JMojica|JMojica]] 09:07~~, ~~2018 December 6~~ (~~CST~~)}}

==== Supplemental data ====

* track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.

@@ Line 20: / Line 20: @@
 === Patients being sent ===
-*{{Discussion}} perhaps tagging things for main office, as indicated below,  should be done differently or in different place 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.
+*{{Discuss| perhaps tagging things for main office, as indicated below,  should be done differently or in different place 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:
@@ Line 32: / Line 32: @@
 also to state if the diagnosis is not confirmed yet etc.
 * diagnosis is still unclear as they are waiting for further tests or results
-** {{discussion}} should such a dx be entered and noted in notes, or '''not''' entered until confirmed and tracked in notes instead? [[User:Ttenbergen|Ttenbergen]] 16:26, 9 November 2010 (CST)
+{{discuss|
-*** this is probably a question for main office, especially now that they use the data before completion. Ttenbergen 14:24, 2014 September 19 (CDT)
+*A dx should not be entered into ICD10 unless it is known and confirmed ([[ICD10_collection#.22Suspected.22_Diagnoses]]). Are collectors still entering unconfirmed dxs into ICD10 and noting so in Notes? This should not be happening... Ttenbergen 10:19, 2019 September 16 (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 a Clear note to self or to collector who is covering you.[[User:TOstryzniuk|Trish Ostryzniuk]] 17:26, 2017 November 20 (CST)
+**if data is INCOMPLETE, main does not rely on DX info.  If DX has not been confirmed, notes field is good place to put a Clear note to self or to collector who is covering you.[[User:TOstryzniuk|Trish Ostryzniuk]] 17:26, 2017 November 20 (CST)
-***** I am not sure that is true, I think Julie uses the [[Primary Admit Diagnosis]] even for incomplete patients. Will flag this question for her.
+*** As confirmed with Julie, Main office uses the [[Primary Admit Diagnosis]] even for incomplete records, so dx codes should not be coded for suspected dxs in ICD10. If we really want to change this, then instructions on [[ICD10_collection#.22Suspected.22_Diagnoses]] need to be made consistent with those on this page. Ttenbergen 10:19, 2019 September 16 (CDT)}}
-{{Discuss | who = Julie | question = * Do you use diagnosis information before patients are complete, e.g.  [[Primary Admit Diagnosis]]?
- Yes, I use the primary diagnosis for the reason of readmission even if the record status is incomplete. --[[User:JMojica|JMojica]] 09:07, 2018 December 6 (CST)}}
 ==== Supplemental data ====
 * track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.