Minimal Data Set: Difference between revisions

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Question for SBGH data collectors (or anyone else who would like to offer an opinion): Where is the most reliable place in the chart to get the admit date and time (i.e. the time that the patient is admitted to your medical service)?

It has been my experience here at SBGH that there is not a consistently reliable place where we can get that information, since there is no one specific "spot" that this information is documented. Our current practise is to use the date and time that is entered on the "INPATIENT SUMMERY SHEET" since this sheet is on every patient's chart. It is my understanding that this time however, is nothing more than the time that the sheet is created by the admitting clerk who enters this information. The downfall of using this sheet's date and time, is that you have to have the chart in front of you to get it. If you are trying to get patients entered with minimal data set, you may not always have the chart in front of you. That means you then need to enter a fake date and time and then have to change it later. Would a more appropriate date and time be the one that is entered on the epr, when the order is written to accept that patient to a particular service? (This too, has flaws I know, because the m.d.'s can sometimes be notoriously lacking, when it comes to writing an order to transfer, especially when transfering patients from acute to non-acute medicine.)

It has been my experience here at SBGH that there is not a consistently reliable place where we can get that information, since there is no one specific "spot" that this information is documented. Our current practise is to use the date and time that is entered on the "INPATIENT SUMMERY SHEET" since this sheet is on every patient's chart. It is my understanding that this time however, is nothing more than the time that the sheet is created by the admitting clerk who enters this information. The downfall of using this sheet's date and time, is that you have to have the chart in front of you to get it. If you are trying to get patients entered with minimal data set, you may not always have the chart in front of you. That means you then need to enter a fake date and time and then have to change it later. Would a more appropriate date and time be the one that is entered on the epr, when the order is written to accept that patient to a particular service? (This too, has flaws I know, because the m.d.'s can sometimes be notoriously lacking, when it comes to writing an order to transfer, especially when transfering patients from acute to non-acute medicine.)--[[User:DPageNewton | DPageNewton]] September 16, 2010.

== Reason why data is required for patients that are not complete yet ==

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 {{Discussion}}
 Question for SBGH data collectors (or anyone else who would like to offer an opinion): Where is the most reliable place in the chart to get the admit date and time (i.e. the time that the patient is admitted to your medical service)?
-It has been my experience here at SBGH that there is not a consistently reliable place where we can get that information, since there is no one specific "spot" that this information is documented. Our current practise is to use the date and time that is entered on the "INPATIENT SUMMERY SHEET" since this sheet is on every patient's chart. It is my understanding that this time however, is nothing more than the time that the sheet is created by the admitting clerk who enters this information. The downfall of using this sheet's date and time, is that you have to have the chart in front of you to get it. If you are trying to get patients entered with minimal data set, you may not always have the chart in front of you. That means you then need to enter a fake date and time and then have to change it later. Would a more appropriate date and time be the one that is entered on the epr, when the order is written to accept that patient to a particular service? (This too, has flaws I know, because the m.d.'s can sometimes be notoriously lacking, when it comes to writing an order to transfer, especially when transfering patients from acute to non-acute medicine.)
+It has been my experience here at SBGH that there is not a consistently reliable place where we can get that information, since there is no one specific "spot" that this information is documented. Our current practise is to use the date and time that is entered on the "INPATIENT SUMMERY SHEET" since this sheet is on every patient's chart. It is my understanding that this time however, is nothing more than the time that the sheet is created by the admitting clerk who enters this information. The downfall of using this sheet's date and time, is that you have to have the chart in front of you to get it. If you are trying to get patients entered with minimal data set, you may not always have the chart in front of you. That means you then need to enter a fake date and time and then have to change it later. Would a more appropriate date and time be the one that is entered on the epr, when the order is written to accept that patient to a particular service? (This too, has flaws I know, because the m.d.'s can sometimes be notoriously lacking, when it comes to writing an order to transfer, especially when transfering patients from acute to non-acute medicine.)--[[User:DPageNewton | DPageNewton]] September 16, 2010.
 == Reason why data is required for patients that are not complete yet ==