Minimal Data Set

Minimal Data Set is entered DAILY into the laptop for all new admissions!

If part A of the minimal data set is not complete for any patient, the CCMDB.mdb will give an "incomplete minimal data set" error and list the patient, and you will not be able to send any patients.

Part A & B must be entered onto the laptop on ALL NEW patients DAILY as soon as possible.

Minimal Data Set Elements

• A. Daily, ALL NEW patients:
  • serial number
  • hospital
  • unit / location
  • first name
  • last name
  • hospital chart number
  • unit admit date (time not necessary)

• B. Daily also, when you are in collecting data , the following also need to be entered onto the laptop as soon as it is available:
  • admit time
  • discharge date and time
    • Importance of discharge DATE

NOTE: The absence of these two items in Part B, will not stop the program from sending.

• • • How discharge date is used in PDA_Pending.mdb
  • data for those TmpV2 entries where instructions say that all data is sent at every send

Data on all patients gets sent to the Regional Server each week that files are sent; see Sending Patients for details.

Instruction STB Med Minimal Data Set - Primary Source for Admit to Medicine Date/time:

• a. For Acute Care Medicine patients at STB, use the Doctors orders on the EPR as date/time accepted to Medicine Service.--TOstryzniuk 17:26, 21 September 2010 (CDT)
• b. for Non Acute Care - C service medicine patients at STB, use_______? for date/time accepted to medicine service.

Discussion

Template: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 practice is to use the date and time that is entered on the "INPATIENT SUMMARY 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 transferring patients from acute to non-acute medicine.)-- DPageNewton September 16, 2010.
  • Good point about where, at your site, each collector should get the most reliable information for admit date/time to medicine service physician”. The practice should be consistent at your site.

Two things important:

1. which is the most reliable source at your site: A. the "INPATIENT SUMMARY SHEET"or B. the Dr.’s order on EPR?
2. Standard collection practice: To be consistent, Collectors at a site must obtain the information from the same source.

• I understand that there will always be variability of admit data and time between Inpatient Summary Sheet and the Dr's on the EPR (Electronic Patient Record). It has been explained to me that sometime the Inpatient Summary Sheet admit date/time is after the Doc order date/time and sometimes it before the Doc orders.
  • Debbie, Elaine and Laura and Kym - where do you get your most reliable source for admit date/time at your site for your unit.--TOstryzniuk 19:04, 16 September 2010 (CDT)
    • Apparently both Deb and Elaine are taking the Date and Time of admission to Medicine Service from the Med Service physician orders on the EPR. Elaine, is that correct?
      • What source does both Elaine and Deb use for date/time admit to non acute C service if Doc's are not writing orders? Please update instruction b above--TOstryzniuk 17:26, 21 September 2010 (CDT)

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

Data from patients who are not yet complete is used for the following:

• to generate occupancy statistics
• to be able to finalize temporary studies before long-stay patients are eventually discharged
• to monitor the number of outstanding patients

Removal of DOB and PHIN from the list

We removed PHIN and DOB from this list because it was causing problems entering patients admitted to our ICUs without identification. Chart Number and location should allow us to identify any such patients conclusively anyway.