Notes field

There is a Notes field on the laptop and in the CCMDB.mdb. This field is for notes during collection only. The notes field expands to a bigger form when you double-click on it

The contents of the notes field are not sent in to the Regional Server with the patient data files. Notes are not stored in TMSX or MedTMS.

• Data Processor will keep 2 years of PDA Status Reports which includes notes on X.

Usage of the notes field

Template:Discussion It was suggested in Requested_CCMDB_changes_for_the_next_version#Notes_field that we might be able to use the notes section on the laptops to keep track of things currently done in paper.

Norine and Jackie at the Vic have been using this field for just that for a long time, and I think their insight could be helpful to others.

However, if this field were to be more commonly used, it would be good if everyone used it in a similar way so it would work for hand-over during vacation or similar just as well as for keeping track for yourself.

You collectors know best what would be helpful. Could you comment on what sort of things you keep track of that this might be helpful for, and what might be a good protocol to do this? As part of this it would be good to know how you keep track of how far you got in a chart, and whatever else a different collector would need to know to finish of a patient you started. I will start a list below here, but free-flow comments are invited as well!

List

• diagnosis is still unclear as they are waiting for further tests or results
• where we have left off & also to state if the diagnosis is not confirmed yet etc.
• track all lab and pharmacy manually, the notes save time in that it eliminates the need to go back & recount.
• to clearly define some admit diagnoses-the ones that come up as other problems, other problems when you enter them.
• to enter info on base creatinine, bmi, or other tidbits of info that are useful to know.
• to define what exactly needs to be entered, when a profile is only partially completed.

Discussion

Any other comments? Ttenbergen 16:18, 16 April 2010 (CDT)

• It's interesting that you'd like to know what method I use to keep track of how far I have gotten in a chart when doing reviews, since there has been a bit of controversy just this morning from one of our doc's regarding this very issue. It has been my practice to make a small mark with a yellow highlighter in the margin of the ipn (integrated progress notes) notes, at the last note that I have read. The next time I go back to review the chart, I look for the yellow highlighter mark. I have now had two of our doc's complain about the tiny unobtrusive mark. Any other suggestions that can be used that will keep our doc's happy, would be much appreciated. Thanks. DPageNewton 17:46, 28 September 2010 (CDT)

• • If the note field is now "readable" by Pagasa could this note field be used to report/confirm an extreme Apache lab or vital signs value was entered and what that value was? Mlaporte 22:20, 3 November 2010 (CDT)
    • If Pagasa reads this note field how long is the information stored for (it would save us pulling charts a few years later )--PStein 14:56, 8 November 2010 (CST)
      • 2 years--TOstryzniuk 16:28, 8 November 2010 (CST)