STB Medicine Collection Guide: Difference between revisions

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~~How to determine when a patient is no longer under an internal medicine service:~~

In the EPR the patient list for 6AS will show the "provider" which should separate family medicine attending physicians from the internal medicine attending physicians. However, because this is not always consistently kept up to date when services change, the following checks can help to determine if a patient remains under internal medicine.

1. In EPR,Check the orders under transfers/care directives, to see if there has been an order to switch from internal medicine to family medicine. If there is use this as your date and time of discharge.

2. In EPR, go to the patient info tab, select care providers from the left hand column, a list should come up with providers and their discipline with a date. If you see that the most recent attending is a family medicine physician then there has likely been a change of service. You may be able to confirm this by checking under the documents tab, sort by discipline, and then check the medicine notes that correspond to the date found in the care providers list. Family medicine progress notes will be identified as such in the notes section. If you determine that they are in fact now under family medicine (with no corresponding order), use the date and time of the attending switch in the care provider list as you discharge date and time

==Medicine Overflow Patients==

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=== Who collects "[[OVER]]s" and EMIP's===

*EMIP's and ~~Overstays~~ at STB are collected on the E5 laptop only.

*EMIP's and Overflows at STB are collected on the E5 laptop only.

==Patients who are on off service wards part of their stay only==

*When a pt comes to E5, E6 or B5 from an off-service ward, the data collector must go to the original presentation of the pt to see if this pt was accepted to medicine on the off-service ward prior to their arrival on their own ward. If you see that the pt was looked after by internal medicine prior to their arrival from the other ward, make sure you start your profile on the original date that medicine accepted them (usually in ER). This way we will not miss any of the patients that are temporarily off the wards that we collect on. For these patients, do not use the overstay designation (OVZ)because that designation is only for those that never get a bed on E5, E6 or B5.

*When a pt comes to E5, E6 or B5 from an off-service ward (this includes 6AS), the data collector must go to the original presentation of the pt to see if this pt was accepted to medicine on the off-service ward prior to their arrival on their own ward. If you see that the pt was looked after by internal medicine prior to their arrival from the other ward, make sure you start your profile on the original date that medicine accepted them (usually in ER). This way we will not miss any of the patients that are temporarily off the wards that we collect on. For these patients, do not use the overstay designation (OVZ)because that designation is only for those that never get a bed on E5, E6 or B5.

*On occasion medicine patients are transferred to off service wards, but are still admitted under the internal medicine service. ie. patient transferred from E6 to 7AS (surgical ward) but still admitted under internal medicine. The attending may be different than the admitting service but it is still an internal medicine attending. Please continue to follow these patients (new profile is '''not''' required) until they are discharged or transferred to an off service ward under family medicine or any other service other than internal med. Please make a note in the "notes" section of the profile. There is no need to fill out any variables on the registration tab.

==How to determine when a patient is no longer under an internal medicine service==

In the EPR the patient list will show the "provider" which should identify which service the attending physicians is from. However, because this is not always consistently kept up to date when services change, the following checks can help to determine if a patient remains under internal medicine or switches to another service.

1. In EPR,Check the orders under transfers/care directives, to see if there has been an order to switch from internal medicine to another service. If there is use this as your date and time of discharge.

2. In EPR, go to the patient info tab, select care providers from the left hand column, a list should come up with providers and their discipline with a date. If you see that the most recent attending is no longer an internal medicine physician then there has likely been a change of service. You may be able to confirm this by checking under the documents tab, sort by discipline, and then check the medicine notes that correspond to the date found in the care providers list. The progress notes from different services will be identified as such in the notes section. If you determine that they are in fact now under a new service (with no corresponding order), use the date and time of the attending switch in the care provider list as your discharge date and time

== work load splitting ==

@@ Line 11: / Line 11: @@
-How to determine when a patient is no longer under an internal medicine service:
-In the EPR the patient list for 6AS will show the "provider" which should separate family medicine attending physicians from the internal medicine attending physicians.  However, because this is not always consistently kept up to date when services change, the following checks can help to determine if a patient remains under internal medicine.
-. In EPR,Check the orders under transfers/care directives, to see if there has been an order to switch from internal medicine to family medicine.  If there is use this as your date and time of discharge.
-. In EPR, go to the patient info tab, select care providers from the left hand column, a list should come up with providers and their discipline with a date.  If you see that the most recent attending is a family medicine physician then there has likely been a change of service.  You may be able to confirm this by checking under the documents tab, sort by discipline, and then check the medicine notes that correspond to the date found in the care providers list. Family medicine progress notes will be identified as such in the notes section. If you determine that they are in fact now under family medicine (with no corresponding order), use the date and time of the attending switch in the care provider list as you discharge date and time
 ==Medicine Overflow Patients==
@@ Line 37: / Line 28: @@
 === Who collects "[[OVER]]s" and EMIP's===
-*EMIP's and Overstays at STB are collected on the E5 laptop only.
+*EMIP's and Overflows at STB are collected on the E5 laptop only.
 ==Patients who are on off service wards part of their stay only==
-*When a pt comes to E5, E6 or B5 from an off-service ward, the data collector must go to the original presentation of the pt to see if this pt was accepted to medicine on the off-service ward prior to their arrival on their own ward.  If you see that the pt was looked after by internal medicine prior to their arrival from the other ward, make sure you start your profile on the original date that medicine accepted them (usually in ER).  This way we will not miss any of the patients that are temporarily off the wards that we collect on.  For these patients, do not use the overstay designation (OVZ)because that designation is only for those that never get a bed on E5, E6 or B5.
+*When a pt comes to E5, E6 or B5 from an off-service ward (this includes 6AS), the data collector must go to the original presentation of the pt to see if this pt was accepted to medicine on the off-service ward prior to their arrival on their own ward.  If you see that the pt was looked after by internal medicine prior to their arrival from the other ward, make sure you start your profile on the original date that medicine accepted them (usually in ER).  This way we will not miss any of the patients that are temporarily off the wards that we collect on.  For these patients, do not use the overstay designation (OVZ)because that designation is only for those that never get a bed on E5, E6 or B5.
 *On occasion medicine patients are transferred to off service wards, but are still admitted under the internal medicine service.  ie. patient transferred from E6 to 7AS (surgical ward) but still admitted under internal medicine.  The attending may be different than the admitting service but it is still an internal medicine attending.  Please continue to follow these patients (new profile is '''not''' required) until they are discharged or transferred to an off service ward under family medicine or any other service other than internal med.   Please make a note in the "notes" section of the profile.  There is no need to fill out any variables on the registration tab.
+==How to determine when a patient is no longer under an internal medicine service==
+In the EPR the patient list will show the "provider" which should identify which service the attending physicians is from.  However, because this is not always consistently kept up to date when services change, the following checks can help to determine if a patient remains under internal medicine or switches to another service.
+. In EPR,Check the orders under transfers/care directives, to see if there has been an order to switch from internal medicine to another service.  If there is use this as your date and time of discharge.
+. In EPR, go to the patient info tab, select care providers from the left hand column, a list should come up with providers and their discipline with a date.  If you see that the most recent attending is no longer an internal medicine physician then there has likely been a change of service.  You may be able to confirm this by checking under the documents tab, sort by discipline, and then check the medicine notes that correspond to the date found in the care providers list. The progress notes from different services will be identified as such in the notes section. If you determine that they are in fact now under a new service (with no corresponding order), use the date and time of the attending switch in the care provider list as your discharge date and time
 == work load splitting ==