STB Electronic Patient Record: Difference between revisions
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Ttenbergen (talk | contribs) We now have a central definition for what to use for these times, so STB should no longer use special collection instructions for this. |
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| Line 14: | Line 14: | ||
* physicians OR notes | * physicians OR notes | ||
* Central line insertions | * Central line insertions | ||
* diagnostic imaging, including echocardiograms | |||
* Cardiac Catheterization reports; access results via link to the right of the document | |||
=== Data documented in paper and EPR === | === Data documented in paper and EPR === | ||
Revision as of 11:04, 1 March 2024
This page documents specific info about EPR data as used by our collectors at STB. For information common to all sites, see EPR.
Implementation Status
All sites are at different stages of EPR implementation. It is fully implemented at STB.
Data only documented in EPR
- data listed at EPR#Data in EPR
- Physician orders
- laboratory
- pharmacy data (MAR)
- integrated progress notes
- nurses operative report
- physicians OR notes
- Central line insertions
- diagnostic imaging, including echocardiograms
- Cardiac Catheterization reports; access results via link to the right of the document
Data documented in paper and EPR
- endoscopy has a paper version and an EPR version.
- heart cath has both paper and EPR versions of the report.
Data still recorded only outside of EPR / on paper
- continuous medication infusions
- vital signs for apache from icu flowsheets,
- amount of blood products delivered from the blood transfusion record sheet
- TEE reports for patients having OHS
- echo reports
- anesthesia record
- blood product sheets (orders for blood should be on EPR) Sometimes the orders and other sources of information (flow sheets, blood product sheets) differ.
- nurses flow sheets
- intake and output sheets
- CRRT sheets
- GCS sheets
Related articles
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