STB ACCU Collection Guide

This article contains collection information specific to the CCU (Cardiac Care Unit) at St Boniface.

Please make sure you document information at the most general level that is applicable, i.e. don't code something that affects all collection at StB in the program or unit level articles.

See the following for more general information:

• STB Collection Guide
• STB Critical Care Collection Guide

Unit admission log book

Where is it stored, in enough detail that another collector could find it? Template:Discussion

Ward contacts

Anyone you need to know about to do your work? Template:Discussion

Collector "base"

Where on the unit do you hang out to do your collection? Template:Discussion

Location of patient chart components

Anything unusual or not intuitive? if not, delete heading/section Template:Discussion

Charting Note

The CCU patient chart has a flow sheet for the nurses to fill out their vital signs and patient assessments. If the patient has had an acute MI, a care map type of flow sheet is used. This has four steps as the patient progresses in their recovery. A second option for nurses’ charting is a CCU flow sheet for all other types of patients other than acute MI. (examples: arrythmias, pre op optimizations, cardiomyopathy, chest pain NYD, etc. ). Occasionally a COR sheet (like those used on the wards) can be continued in CCU and even the Y2 procedure note page has been continued on a rare occasion for a patient who needs some CCU management post angio.

Post-Angio patients exclusion

We do not collect patients who arrive in CCU for post procedure care post angio only because the pre and post angio area is closed.

STEMI code for From/To slots

Some heart attack patients are admitted straight to the heart cath lab without being admitted to the. See STEMI for collection instructions for such patients.

Diagnostic Coding vs Admit-From

Primary angiograms are those that go first to the angio room and then to CCU afterwards. In this case the first admit diagnosis should be angiogram, then angioplasty, then stent, then the MI with location subcode and then other items like CHF or TNK if applicable. The exception to this rule is when the patient has a cardiac arrest before arriving in CCU or has cardiogenic shock. These will then be coded first and then the primary angio sequence. If you are past the quota for number of admit diagnosis codes, you can use only angioplasty if necessary (take out angiogram and stent if needed).

If the patient comes from an ICU (different hospital) do not use the MI as the first diagnosis. Other options could be post infarct angina, unstable angina, chf, cardiogenic shock, etc. The second diagnosis could be the MI.

TISS

If the patient is a primary angio, item #91 (what's 91) Template:Discussion should not be marked. However if the patient had a plasty, #96 operative procedure can (can or must?) Template:Discussion be marked. If the angio happens as a complication (after arriving in CCU), then #91 can be marked.

If the patient has a temporary pacemaker, make sure one of the Tiss items #15 or 16 is marked for each day the patient has the pacemaker. If the patient goes for a permanent pacemaker, the OR #96 must be marked and then the next day the #15 or 16 should not be marked. If the permanent pacemaker is done and then the patient goes to the cardiology ward afterwards and does not return to CCU, #96 is not marked and the code permanent pacemaker is not entered as a complication. The patient is instead transferred to the OR and the profile is completed.

Discussion

• Again, is this truly special to the CCU? These sound like general TISS instructions that should be addressed in . Ttenbergen 16:36, 1 October 2009 (CDT)