ACP Status collection in ICU: Difference between revisions
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== Coding Instructions == | == Coding Instructions == | ||
When you enter a new ICU patient two records will be automatically generated in the tmp table: | When you enter a new ICU patient two records will be automatically generated in the tmp table: | ||
* '''ACP Status at admit''' (ie within 6 hours of admission) | * '''ACP Status at admit''' (ie within 6 hours of admission) Note: if the pt already has an ACP status in the chart prior to admission to the ICU, this status can be used at admission to the ICU, unless it changes in the first 6 hours in the ICU. | ||
* '''ACP Status at end''' (ie at end of stay resp. at death) | * '''ACP Status at end''' (ie at end of stay resp. at death). If the pt has care D/C'ed do not automatically change the ACP to C. Use the last documented ACP on the chart for the end ACP. | ||
Change the ITEM for each of them to the ACP status at that time. Options are as follows | Change the ITEM for each of them to the ACP status at that time. Options are as follows | ||
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* '''ACP M-''' - all medical care given except resuscitation and intubation | * '''ACP M-''' - all medical care given except resuscitation and intubation | ||
* '''ACP n/a''' - no documented ACP on the chart | * '''ACP n/a''' - no documented ACP on the chart | ||
* Note: If you cannot find any mention of ACP on the chart, do not default to ACP-R, Put ACP n/a as above instructions indicate. (Verified with Kendiss Olafson on August 18, 2015). | * Note: If you cannot find any mention of ACP on the chart, do not default to ACP-R, Put ACP n/a as above instructions indicate. Also, the documented ACP is not present in the first 6 hours of admission, use ACP n/a for the admission. (Verified with Kendiss Olafson on August 18, 2015). | ||
'''Don't fill''' Checkbox, dates, numbers, not used for this project | '''Don't fill''' Checkbox, dates, numbers, not used for this project | ||
Revision as of 15:02, 2015 September 10
see Comfort Care for collection of similar info in Medicine
This article is about collecting the "ACP Status" temp entry.
Coding Instructions
When you enter a new ICU patient two records will be automatically generated in the tmp table:
- ACP Status at admit (ie within 6 hours of admission) Note: if the pt already has an ACP status in the chart prior to admission to the ICU, this status can be used at admission to the ICU, unless it changes in the first 6 hours in the ICU.
- ACP Status at end (ie at end of stay resp. at death). If the pt has care D/C'ed do not automatically change the ACP to C. Use the last documented ACP on the chart for the end ACP.
Change the ITEM for each of them to the ACP status at that time. Options are as follows
- ACP C - comfort care
- ACP R - full resuscitation
- ACP M+ - all medical care given except cardiac resuscitation; intubation either happened or allowed
- ACP M- - all medical care given except resuscitation and intubation
- ACP n/a - no documented ACP on the chart
- Note: If you cannot find any mention of ACP on the chart, do not default to ACP-R, Put ACP n/a as above instructions indicate. Also, the documented ACP is not present in the first 6 hours of admission, use ACP n/a for the admission. (Verified with Kendiss Olafson on August 18, 2015).
Don't fill Checkbox, dates, numbers, not used for this project
What if ACP-M is documented without +/-?
If ACP M is just written with no qualifiers then one would classify as ACP M-.
WRHA guidelines
See http://www.wrha.mb.ca/acp/files/Workbook.pdf for the WRHA ACP Guidelines.
Start and stop date
- Start Date: 2015-08-10
- Stop Date: none
Template:CCMDB Data Integrity Checks
Data use / Reporting and Analysis
- would allow QI team to follow:
- % of patient with documented ACP during ICU
- Level of care at both admission and discharge
- % of patients with change in level of care during ICU
- Level of care at the time of ICU death
RE Patients admitted prior to August 10
I spoke with Julie about this and she said to put in the ACP status on all your patients if it is not too much trouble when you have the charts. If you have finished reviewing charts and they are complete, don’t bother going back to look for the ACP status. There will probably be a week transition period given before she starts gleaning this data to give us time to get used to collecting this information. Hope this helps. Laura