Lost/missing chart

Deferral period

• A chart should be considered lost or missing, and "written off", when medical records still cannot find it 6 months (same day number, 6 months later) after the patient has been discharged from the hospital or died in hospital.
• Once that occurs, the record status will be updated to "Discontinued".
• Operationally, this will be done via ad hoc communication with the office (Pagasa).

Instructions for finishing off the profile

An profile for a missing chart might trigger CCMDB.accdb Data Integrity Checks, so it can't be sent the normal way and the following process applies instead.

Instructions for Collectors

• Try to enter all available info and to check the complete boxes; this will make sure that data is internally consistent as far as possible
  • This includes any diagnostic imaging and procedure counts and results, lab results, etc
• Where you can not get past a cross check because data is not available, explain that in the Notes field

what should be the instruction for APACHE - the usual "enter normal if not available" or should they enter extremes or 0s, or leave blank? What will not mess with Julie's processes? I would rather have a missing APACHE Score when any of the APACHE elements are missing due to Lost or missing chart. Entry of zero for numeric or blank for character on any of the elements results to blank APACHE Score (but this refutes the guideline for APACHE Physiologic Not available). Normal values result to Zero APACHE Score (when age pts is zero).

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• When you have entered all available information, and when the #Deferral period has passed, contact Pagasa and tell her the profile is a missing/lost chart
• Once Pagasa has confirmed that this is understood, delete the chart using the ♻️ button

Instructions for Data Processor

The Data Processor will manually set the RecordStatus for these to "Discontinued"; information on the lost chart status can be entered into the Notes field.

Pagasa, please let Tina know if these profiles with RecordStatus "Discontinued" are falsely triggering any cross checks in CFE. Ttenbergen 14:36, 2021 June 15 (CDT) Julie says Pagasa keeps a list of old lost charts. Could you do a one-time update to set the relevant records to Discontinued in CFE and then get rid of that list.

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HSC_D5-36 HSC_D5-39 HSC_D4-3 HSC_SICb-1409 HSC_SICa-1887 STB_MICU-15213